Provider Demographics
NPI:1134305501
Name:JOHNSON, WANDA (LCSW)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
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 1:91 CAMDEN STREET
Mailing Address - Street 2:SUITE 206
Mailing Address - City:ROCKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04841
Mailing Address - Country:US
Mailing Address - Phone:207-594-6699
Mailing Address - Fax:
Practice Address - Street 1:91 CAMDEN STREET
Practice Address - Street 2:SUITE 206
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841
Practice Address - Country:US
Practice Address - Phone:207-594-6699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC98671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical