Provider Demographics
NPI:1699838508
Name:JOHNSON, MYRA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MYRA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:MYRA
Other - Middle Name:JOHNSON
Other - Last Name:HALE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:1453 HOPE WAY
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-3140
Mailing Address - Country:US
Mailing Address - Phone:615-893-9390
Mailing Address - Fax:
Practice Address - Street 1:111 W COURT SQ
Practice Address - Street 2:SUITE 3
Practice Address - City:MC MINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-2589
Practice Address - Country:US
Practice Address - Phone:931-507-5279
Practice Address - Fax:931-507-5281
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000036801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3151751OtherBLUE CROSS BLUE SHIELD
TN3921034Medicaid
TN3921034Medicaid