Provider Demographics
NPI:1033616453
Name:JOHNSON, CARMELLA (LSW)
Entity Type:Individual
Prefix:
First Name:CARMELLA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9161 CRESCENT BLVD
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44147-3912
Mailing Address - Country:US
Mailing Address - Phone:216-854-9567
Mailing Address - Fax:
Practice Address - Street 1:12395 MCCRACKEN RD
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2967
Practice Address - Country:US
Practice Address - Phone:216-587-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0017686104100000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator