Provider Demographics
NPI:1659308351
Name:JOHNSON, CAROL ANN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:ANN
Other - Last Name:MEUNIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 EAST FIRST STREET
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805
Mailing Address - Country:US
Mailing Address - Phone:218-728-4404
Mailing Address - Fax:218-728-4404
Practice Address - Street 1:1401 E 1ST ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2407
Practice Address - Country:US
Practice Address - Phone:218-728-4491
Practice Address - Fax:218-728-4404
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
134701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN722632200Medicaid