Provider Demographics
NPI:1043488703
Name:JOHANNESSEN, LARRY NORMAN (PHD MSW LCSW MDIV)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:NORMAN
Last Name:JOHANNESSEN
Suffix:
Gender:M
Credentials:PHD MSW LCSW MDIV
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Other - First Name:
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Mailing Address - Street 1:825 GUMBRANCH RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540
Mailing Address - Country:US
Mailing Address - Phone:910-455-5551
Mailing Address - Fax:910-938-2556
Practice Address - Street 1:825 GUMBRANCH RD
Practice Address - Street 2:SUITE 109
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540
Practice Address - Country:US
Practice Address - Phone:910-455-5551
Practice Address - Fax:910-938-2556
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NCC003820104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker