Provider Demographics
NPI:1578106845
Name:JOHNSON, MARY MARGARET (LCSWA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MARGARET
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2843 HERMITAGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103
Mailing Address - Country:US
Mailing Address - Phone:336-972-7072
Mailing Address - Fax:
Practice Address - Street 1:6614 SHALLOWFORD RD. SUITE 250
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27023
Practice Address - Country:US
Practice Address - Phone:336-945-0137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-19
Last Update Date:2019-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP013190104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker