Provider Demographics
NPI:1497707764
Name:JOHNSON, MICHELLE RENAE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:RENAE
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 1:100 NEW SALEM RD
Mailing Address - Street 2:SUITE 116
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401-8936
Mailing Address - Country:US
Mailing Address - Phone:724-437-0729
Mailing Address - Fax:724-437-2761
Practice Address - Street 1:1051 MORRELL AVE
Practice Address - Street 2:
Practice Address - City:CONNELLSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15425-3958
Practice Address - Country:US
Practice Address - Phone:724-437-0729
Practice Address - Fax:724-437-2761
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0144991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1430686OtherHIGHMARK
PA001931501Medicaid
P57751Medicare UPIN
PA001931501Medicaid