Provider Demographics
NPI:1467531996
Name:JOHNSON, S LORI (LCSW)
Entity Type:Individual
Prefix:
First Name:S
Middle Name:LORI
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 1:10112 W OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1428
Mailing Address - Country:US
Mailing Address - Phone:208-780-3900
Mailing Address - Fax:
Practice Address - Street 1:10112 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1428
Practice Address - Country:US
Practice Address - Phone:208-780-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2016-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCSW11471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010143042OtherBLUE SHIELD
IDL1302OtherBLUE CROSS
ID1477920270Medicaid
ID1477920270Medicaid