Provider Demographics
NPI:1750642070
Name:JOHNSON, STEPHANIE R (PLCSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PLCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 TRACY DR
Mailing Address - Street 2:# H
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-6147
Mailing Address - Country:US
Mailing Address - Phone:843-337-9312
Mailing Address - Fax:336-570-1351
Practice Address - Street 1:1708 S MEBANE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-6590
Practice Address - Country:US
Practice Address - Phone:336-229-4624
Practice Address - Fax:336-570-1351
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0069731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical