Provider Demographics
NPI:1114363140
Name:JOHNSON, CAROL MARTIN (MA, ATR-BC, LPC)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:MARTIN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, ATR-BC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4708 KINGSESSING AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-3819
Mailing Address - Country:US
Mailing Address - Phone:215-729-1297
Mailing Address - Fax:
Practice Address - Street 1:4708 KINGSESSING AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-3819
Practice Address - Country:US
Practice Address - Phone:215-729-1297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-16
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC004304101YP2500X
PARN264361L163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No163W00000XNursing Service ProvidersRegistered Nurse