Provider Demographics
NPI:1578658381
Name:JOHNSON-ETIENNE, PRISTINA (LCSW)
Entity Type:Individual
Prefix:
First Name:PRISTINA
Middle Name:
Last Name:JOHNSON-ETIENNE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:PRISTINA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2511 APPLEGATE DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-8404
Mailing Address - Country:US
Mailing Address - Phone:704-796-6518
Mailing Address - Fax:
Practice Address - Street 1:13534 PLAZA ROAD EXT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-8921
Practice Address - Country:US
Practice Address - Phone:704-796-6518
Practice Address - Fax:704-631-2426
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0047461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106128Medicaid
NC6106128Medicaid