Provider Demographics
NPI:1114005667
Name:KATHRYN JOHNSON
Entity Type:Organization
Organization Name:KATHRYN JOHNSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOSOCIAL CLINICIAN II
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:352-988-4181
Mailing Address - Street 1:5655 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-4289
Mailing Address - Country:US
Mailing Address - Phone:407-895-4100
Mailing Address - Fax:407-422-4492
Practice Address - Street 1:4400 N HIGHWAY 19A
Practice Address - Street 2:SUITE 4
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2032
Practice Address - Country:US
Practice Address - Phone:352-988-4181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW 6550OtherSOCIAL WORK LICENSE