Provider Demographics
NPI:1467967158
Name:JOHNSON, DIETRICH B (LGSW)
Entity Type:Individual
Prefix:MS
First Name:DIETRICH
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 W VIRGINIA AVE NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-3829
Mailing Address - Country:US
Mailing Address - Phone:202-806-9847
Mailing Address - Fax:
Practice Address - Street 1:915 RHODE ISLAND AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-4153
Practice Address - Country:US
Practice Address - Phone:202-232-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLG50081743104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty