Provider Demographics
NPI:1114014446
Name:JOHANSEN, SUSAN BRAGDON (LPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:BRAGDON
Last Name:JOHANSEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 EMERY HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217
Mailing Address - Country:US
Mailing Address - Phone:478-751-4446
Mailing Address - Fax:478-751-4444
Practice Address - Street 1:175 EMERY HIGHWAY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217
Practice Address - Country:US
Practice Address - Phone:478-751-4446
Practice Address - Fax:478-751-4444
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003160101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003160OtherLPC