Provider Demographics
NPI:1477706232
Name:JOHNSON, NICOLE
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:JOHNSON ROBERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7207 RAVENWOOD LN
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-7520
Mailing Address - Country:US
Mailing Address - Phone:973-919-2165
Mailing Address - Fax:
Practice Address - Street 1:7207 RAVENWOOD LN
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-7520
Practice Address - Country:US
Practice Address - Phone:973-919-2165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-24
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0040451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical