Provider Demographics
NPI:1407386550
Name:JOHNSON, RAE (LSW, LCDCIII)
Entity Type:Individual
Prefix:
First Name:RAE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LSW, LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 S MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45011-3216
Mailing Address - Country:US
Mailing Address - Phone:513-868-5111
Mailing Address - Fax:513-737-8196
Practice Address - Street 1:820 S MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011-3216
Practice Address - Country:US
Practice Address - Phone:513-868-5111
Practice Address - Fax:513-737-8196
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0025380104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker