Provider Demographics
NPI:1073938254
Name:JOHNSON, IMANI NIA (MS, MSW, LCSWA)
Entity Type:Individual
Prefix:MS
First Name:IMANI
Middle Name:NIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 CHIPPENDALE TRL
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-9344
Mailing Address - Country:US
Mailing Address - Phone:919-718-7754
Mailing Address - Fax:
Practice Address - Street 1:2700 CHIPPENDALE TRL
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-9344
Practice Address - Country:US
Practice Address - Phone:919-718-7754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0075851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical