Provider Demographics
NPI:1417166455
Name:JOHNSON, SHIRLEY LARAINE (LCSW)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:LARAINE
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 1:33 N CENTRAL AVE
Mailing Address - Street 2:SUITE 320
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-5900
Mailing Address - Country:US
Mailing Address - Phone:541-890-3066
Mailing Address - Fax:541-779-3260
Practice Address - Street 1:33 N CENTRAL AVE
Practice Address - Street 2:SUITE 320
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-5900
Practice Address - Country:US
Practice Address - Phone:541-890-3066
Practice Address - Fax:541-779-3260
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL29381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical