Provider Demographics
NPI:1568880680
Name:JOHNSON, SUSAN CRUMLEY (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:CRUMLEY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:KATRINA
Other - Last Name:CRUMLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:430 E LAURIDSEN BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-7978
Mailing Address - Country:US
Mailing Address - Phone:360-457-1610
Mailing Address - Fax:
Practice Address - Street 1:430 E LAURIDSEN BLVD
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-7978
Practice Address - Country:US
Practice Address - Phone:360-457-1610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-05
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-31561041C0700X
WALW606018391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid