Provider Demographics
NPI:1003072364
Name:JOHNSON, MICHAEL KENDRICK (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KENDRICK
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 8TH ST NE
Mailing Address - Street 2:#E-2
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-4282
Mailing Address - Country:US
Mailing Address - Phone:678-895-8412
Mailing Address - Fax:404-879-0779
Practice Address - Street 1:343 8TH ST NE
Practice Address - Street 2:#E-2
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-4282
Practice Address - Country:US
Practice Address - Phone:678-895-8412
Practice Address - Fax:404-879-0779
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-05
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0038821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA316564733AMedicaid
GA316564733AMedicaid