Provider Demographics
NPI:1780672915
Name:JOHNSON, RODERICK VERNE (LCSW)
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:VERNE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 E 4500 S
Mailing Address - Street 2:SUITE 302
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3002
Mailing Address - Country:US
Mailing Address - Phone:801-685-9600
Mailing Address - Fax:801-268-3777
Practice Address - Street 1:860 E 4500 S
Practice Address - Street 2:SUITE 302
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-3002
Practice Address - Country:US
Practice Address - Phone:801-685-9600
Practice Address - Fax:801-268-3777
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT134722-3501101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
870575977OtherTIN
870575977OtherTIN
005736601Medicare ID - Type Unspecified
005737501Medicare ID - Type Unspecified