Provider Demographics
NPI:1235570797
Name:JOHNSON, SHONTALE DENISE (LCSW)
Entity Type:Individual
Prefix:
First Name:SHONTALE
Middle Name:DENISE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 N MULDOON RD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-6104
Mailing Address - Country:US
Mailing Address - Phone:907-257-4700
Mailing Address - Fax:
Practice Address - Street 1:1201 N MULDOON RD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-6104
Practice Address - Country:US
Practice Address - Phone:907-257-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-12
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK437104100000X
AK1197841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker