Provider Demographics
NPI:1134465263
Name:JOHNSON, KURT M (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KURT
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 BRIDGEWATER RD APT C8
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-6309
Mailing Address - Country:US
Mailing Address - Phone:309-631-0058
Mailing Address - Fax:
Practice Address - Street 1:1606 BROAD ST
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-5081
Practice Address - Country:US
Practice Address - Phone:334-480-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-18
Last Update Date:2018-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0143791041C0700X
AL4127C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical