Provider Demographics
NPI:1487826848
Name:JOHNSON, NICHOLE LUSHAWN (LCSW, LCAS)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:LUSHAWN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25238
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-5003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:351 WAGONER DR STE 310
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-4674
Practice Address - Country:US
Practice Address - Phone:910-849-2763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NCC0069331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1487826848Medicaid