Provider Demographics
NPI:1114633757
Name:JOHNSON, KOURTNIE (LCSWA)
Entity Type:Individual
Prefix:
First Name:KOURTNIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4870 NEWPORT CT
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27856-3303
Mailing Address - Country:US
Mailing Address - Phone:617-528-8966
Mailing Address - Fax:
Practice Address - Street 1:4870 NEWPORT CT
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:NC
Practice Address - Zip Code:27856-3303
Practice Address - Country:US
Practice Address - Phone:617-528-8966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA227061104100000X
NCP018591104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker