Provider Demographics
NPI:1275686453
Name:JOHNSON, MARK (LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 NEW LONDON TPKE
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-6552
Mailing Address - Country:US
Mailing Address - Phone:860-886-9324
Mailing Address - Fax:860-886-6182
Practice Address - Street 1:511 NEW LONDON TPKE
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-6552
Practice Address - Country:US
Practice Address - Phone:860-886-9324
Practice Address - Fax:860-886-6182
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0056991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical