Provider Demographics
NPI:1164642294
Name:JOHNSON, DENISE (LSW, LMHC)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LSW, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4720 GUILFORD AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-1956
Mailing Address - Country:US
Mailing Address - Phone:317-283-3270
Mailing Address - Fax:317-283-2685
Practice Address - Street 1:4720 GUILFORD AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-1956
Practice Address - Country:US
Practice Address - Phone:317-283-3270
Practice Address - Fax:317-283-2685
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000912A101YM0800X, 101YP1600X, 101YP2500X
IN33003101A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN33003101AOtherSOCIAL WORKER LICENSE
IN39000912AOtherMENTAL HEALTH COUNSELOR
IN39000912AOtherPASTORAL CARE COUNSELOR