Provider Demographics
NPI:1043972508
Name:JOHNSON, INDIA ROSE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:INDIA
Middle Name:ROSE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3802 E BASELINE RD APT 3102
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-7254
Mailing Address - Country:US
Mailing Address - Phone:734-741-3401
Mailing Address - Fax:
Practice Address - Street 1:10613 N HAYDEN RD STE J103
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-5683
Practice Address - Country:US
Practice Address - Phone:734-741-3401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-181861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical