Provider Demographics
NPI:1396816385
Name:JOHNSON, TRACEY L (LISW-CP)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 36144
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-0502
Mailing Address - Country:US
Mailing Address - Phone:803-334-4056
Mailing Address - Fax:
Practice Address - Street 1:150 OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-4073
Practice Address - Country:US
Practice Address - Phone:803-334-4056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC69701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCJ5560OtherRAILROAD MEDICARE
SC570629234006OtherBCBS
SCCJ5560OtherRAILROAD MEDICARE