Provider Demographics
NPI:1235418120
Name:JOHNSON, CARLY (MA)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1164 S ACOMA ST
Mailing Address - Street 2:337
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-1592
Mailing Address - Country:US
Mailing Address - Phone:215-901-7060
Mailing Address - Fax:
Practice Address - Street 1:4371 E 72ND AVE
Practice Address - Street 2:
Practice Address - City:COMMERCE CITY
Practice Address - State:CO
Practice Address - Zip Code:80022-1471
Practice Address - Country:US
Practice Address - Phone:303-853-3456
Practice Address - Fax:303-289-6962
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health