Provider Demographics
NPI:1760416655
Name:JOHNSON, NANCY CLARE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:CLARE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27001 ANDREW JACKSON HWY
Mailing Address - Street 2:COMMUNITY SUPPORT AGENCY, LLC
Mailing Address - City:DELCO
Mailing Address - State:NC
Mailing Address - Zip Code:28436
Mailing Address - Country:US
Mailing Address - Phone:910-655-0698
Mailing Address - Fax:910-655-0611
Practice Address - Street 1:27001 ANDREW JACKSON HWY
Practice Address - Street 2:COMMUNITY SUPPORT AGENCY, LLC
Practice Address - City:DELCO
Practice Address - State:NC
Practice Address - Zip Code:28436
Practice Address - Country:US
Practice Address - Phone:910-655-0698
Practice Address - Fax:910-655-0611
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0035131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2036462OtherSIGNA
NC2873331BOtherMEDICARE SIGNA
NC11612297OtherCAQH
NC136MEOtherNC BLUE CROSS BLUE SHIELD
NC196994OtherMED COST
NC6002506Medicaid
NC287331BMedicaid