Provider Demographics
NPI:1841744281
Name:JOHNSON, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 BROOKTREE RD STE 208
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-9475
Mailing Address - Country:US
Mailing Address - Phone:724-799-8558
Mailing Address - Fax:
Practice Address - Street 1:6500 BROOKTREE RD STE 208
Practice Address - Street 2:
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-9475
Practice Address - Country:US
Practice Address - Phone:724-799-8558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-13
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0188241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical