Provider Demographics
NPI:1609543958
Name:JOHNSON, ROBERTA ELAYNE-NICOLE (LMSW)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:ELAYNE-NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 MUIR ST STE A
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613-1848
Mailing Address - Country:US
Mailing Address - Phone:410-228-4045
Mailing Address - Fax:833-908-2286
Practice Address - Street 1:503 MUIR ST STE A
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-1848
Practice Address - Country:US
Practice Address - Phone:410-228-4045
Practice Address - Fax:833-908-2286
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24486104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker