Provider Demographics
NPI:1922384320
Name:JOHNSON, DIANNE STANFORD (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:STANFORD
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 1:5222 HUNTINGFORD TER
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-1728
Mailing Address - Country:US
Mailing Address - Phone:770-598-1700
Mailing Address - Fax:
Practice Address - Street 1:601 BOMBAY LN
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5828
Practice Address - Country:US
Practice Address - Phone:770-754-4674
Practice Address - Fax:770-754-4676
Is Sole Proprietor?:No
Enumeration Date:2011-10-29
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW005475104100000X
GACSW0052631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical