Provider Demographics
NPI:1346664372
Name:JOHNSON, EDRIA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:EDRIA
Middle Name:
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 1:20015 S LAGRANGE RD # 1450
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-3104
Mailing Address - Country:US
Mailing Address - Phone:708-945-2647
Mailing Address - Fax:
Practice Address - Street 1:4801 SOUTHWICK DR STE 300
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-2279
Practice Address - Country:US
Practice Address - Phone:708-945-2647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-11
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst