Provider Demographics
NPI:1346594124
Name:JOHNSON, REBECCA J (LISW-S)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3095 KETTERING BLVD
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1983
Mailing Address - Country:US
Mailing Address - Phone:937-534-1528
Mailing Address - Fax:937-534-1350
Practice Address - Street 1:3095 KETTERING BLVD
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1983
Practice Address - Country:US
Practice Address - Phone:937-534-1528
Practice Address - Fax:937-534-1350
Is Sole Proprietor?:No
Enumeration Date:2012-11-01
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI0028347104100000X
OHI.2002255-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker