Provider Demographics
NPI:1508961178
Name:JOHNSON, REBECCA LEE (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LEE
Other - Last Name:FLYNT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27360
Mailing Address - Country:US
Mailing Address - Phone:336-472-0185
Mailing Address - Fax:
Practice Address - Street 1:17 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360
Practice Address - Country:US
Practice Address - Phone:336-472-0185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0040611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003285Medicaid
NC6003285Medicaid