Provider Demographics
NPI:1275720286
Name:JOHNSON, GLORIA A (MSW)
Entity Type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3642 ROSEWOOD ST
Mailing Address - Street 2:B
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-9117
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3624 ROSEWOOD ST.
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32080
Practice Address - Country:US
Practice Address - Phone:904-494-2851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-03
Last Update Date:2007-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW 41501041C0700X
FL41501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical