Provider Demographics
NPI:1578756557
Name:JOHNSON, SHURELL R (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:SHURELL
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E 34TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-3754
Mailing Address - Country:US
Mailing Address - Phone:317-860-3949
Mailing Address - Fax:317-926-1507
Practice Address - Street 1:401 E 34TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-3754
Practice Address - Country:US
Practice Address - Phone:317-860-3949
Practice Address - Fax:317-926-1507
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33004155A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker