Provider Demographics
NPI:1821697616
Name:JOHNSON, NICOLE (LMSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 REDMOND LOOP
Mailing Address - Street 2:
Mailing Address - City:GLENMORA
Mailing Address - State:LA
Mailing Address - Zip Code:71433-4840
Mailing Address - Country:US
Mailing Address - Phone:318-791-6226
Mailing Address - Fax:
Practice Address - Street 1:1414 7TH AVENUE
Practice Address - Street 2:
Practice Address - City:GLENMORA
Practice Address - State:LA
Practice Address - Zip Code:71433
Practice Address - Country:US
Practice Address - Phone:318-748-8145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15492104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker