Provider Demographics
NPI:1417084559
Name:JOHNSON, ELIZABETH GAIL (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:GAIL
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 1:13380 W TREPANIA RD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-2186
Mailing Address - Country:US
Mailing Address - Phone:715-638-5100
Mailing Address - Fax:715-634-6107
Practice Address - Street 1:13380 W TREPANIA RD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-2186
Practice Address - Country:US
Practice Address - Phone:715-638-5100
Practice Address - Fax:715-634-6107
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14818101YA0400X
WI72751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)