Provider Demographics
NPI:1073579306
Name:JOHNSON, TINA (LICSW)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 S DESPERADO DR
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-7356
Mailing Address - Country:US
Mailing Address - Phone:701-261-9685
Mailing Address - Fax:701-346-1100
Practice Address - Street 1:799 COVE PKWY
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4683
Practice Address - Country:US
Practice Address - Phone:701-261-9685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-178131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1454874Medicaid
ND19105Medicaid
MN51Q21JOOtherMN BC/BS
ND15811Medicare ID - Type Unspecified