Provider Demographics
NPI:1700404118
Name:JOHNSON, CANDACE (LCSW)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:BENHAM
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1210 WOLFE ST.
Mailing Address - Street 2:SLOT 654
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202
Mailing Address - Country:US
Mailing Address - Phone:501-364-5150
Mailing Address - Fax:501-364-3966
Practice Address - Street 1:4301 W MARKHAM ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:501-526-8100
Practice Address - Fax:501-526-5296
Is Sole Proprietor?:No
Enumeration Date:2020-07-12
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4509-C104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker