Provider Demographics
NPI:1740384809
Name:JOHNSON, ROBERT E (ACSW, LCSW)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:ACSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:47362-4218
Mailing Address - Country:US
Mailing Address - Phone:765-284-0879
Mailing Address - Fax:765-284-1480
Practice Address - Street 1:3111 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-4371
Practice Address - Country:US
Practice Address - Phone:765-284-0879
Practice Address - Fax:765-284-1480
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004053A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100333710Medicaid
IN134216000OtherMAGELLAN
IN000000186224OtherANTHEM BCBS
IN209030GMedicare ID - Type Unspecified
IN100333710Medicaid