Provider Demographics
NPI:1093722241
Name:JOHNSON, LA TARA T (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LA TARA
Middle Name:T
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 IMPERIAL HILL DR
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-7119
Mailing Address - Country:US
Mailing Address - Phone:770-982-3279
Mailing Address - Fax:
Practice Address - Street 1:1299 METROPOLITAN PKWY SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-4449
Practice Address - Country:US
Practice Address - Phone:404-762-4111
Practice Address - Fax:404-762-4109
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0035281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical