Provider Demographics
NPI:1164505129
Name:JOHNSON, MISTI NICOLE-SMITH (LISW)
Entity Type:Individual
Prefix:MRS
First Name:MISTI
Middle Name:NICOLE-SMITH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 S 3RD AVE E
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:IA
Mailing Address - Zip Code:50208-4239
Mailing Address - Country:US
Mailing Address - Phone:641-792-8020
Mailing Address - Fax:
Practice Address - Street 1:1201 63RD ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50311-1943
Practice Address - Country:US
Practice Address - Phone:641-831-3261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA064661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical