Provider Demographics
NPI:1497390330
Name:JOHNSON, JOYCE R
Entity Type:Individual
Prefix:
First Name:JOYCE
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 S PLEASANT GROVE BLVD APT 5104
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-2717
Mailing Address - Country:US
Mailing Address - Phone:801-471-1298
Mailing Address - Fax:
Practice Address - Street 1:1555 W 2200 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-1429
Practice Address - Country:US
Practice Address - Phone:801-886-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9457467-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker