MEDICARE: PRISTINA JOHNSON-ETIENNE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	C004746	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578658381
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRISTINA JOHNSON-ETIENNE LCSW

Provider Business Mailing Address
First Line	:	2511 APPLEGATE DR
Second Line	:
City	:	CONCORD
State	:	NC
Zip	:	28027-8404
Country	:	US
Telephone Number	:	704-796-6518
Fax Number	:

Provider Business Practice Location Address
First Line	:	13534 PLAZA ROAD EXT
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28215-8921
Country	:	US
Telephone Number	:	704-796-6518
Fax Number	:	704-631-2426

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	04/16/2010

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Directions to “ PRISTINA JOHNSON-ETIENNE LCSW” Practice Location

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