Provider Demographics
NPI:1164136594
Name:JOHNSON, KYNDRA JOY (LISW-CP)
Entity Type:Individual
Prefix:
First Name:KYNDRA
Middle Name:JOY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 DRAYTON ST
Mailing Address - Street 2:
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-2514
Mailing Address - Country:US
Mailing Address - Phone:803-410-0781
Mailing Address - Fax:
Practice Address - Street 1:421 W BOYCE ST
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-2615
Practice Address - Country:US
Practice Address - Phone:803-696-4195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC153291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical