Provider Demographics
NPI:1417276031
Name:JOHNSON, ERIC T (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:T
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2334 W LAWRENCE AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-1948
Mailing Address - Country:US
Mailing Address - Phone:773-456-9379
Mailing Address - Fax:443-460-9379
Practice Address - Street 1:710 N WEBB AVE
Practice Address - Street 2:
Practice Address - City:REEDSBURG
Practice Address - State:WI
Practice Address - Zip Code:53959-1149
Practice Address - Country:US
Practice Address - Phone:608-524-5151
Practice Address - Fax:608-524-5353
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-21
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0118321041C0700X
WI8441-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical