Provider Demographics
NPI:1598848921
Name:JOHNSON, MARY KAY (LCSW CSW PIP QMNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KAY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW CSW PIP QMNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KAY
Other - Last Name:FISCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW CSW PIP QMNP
Mailing Address - Street 1:1103 JENSON AVE SE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-5259
Mailing Address - Country:US
Mailing Address - Phone:605-878-1234
Mailing Address - Fax:605-878-2211
Practice Address - Street 1:1103 JENSON AVE SE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-5259
Practice Address - Country:US
Practice Address - Phone:605-878-1234
Practice Address - Fax:605-878-2211
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLCSW 1557104100000X
SDCSW PIP 1991104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6571100Medicaid
SD41787Medicare ID - Type Unspecified