Provider Demographics
NPI:1922579234
Name:JOHNSON, AMANDA (LMSW)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
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 1:701 ZELLWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:TALLADEGA
Mailing Address - State:AL
Mailing Address - Zip Code:35160-7495
Mailing Address - Country:US
Mailing Address - Phone:256-368-3169
Mailing Address - Fax:
Practice Address - Street 1:701 ZELLWOOD CIR
Practice Address - Street 2:
Practice Address - City:TALLADEGA
Practice Address - State:AL
Practice Address - Zip Code:35160
Practice Address - Country:US
Practice Address - Phone:256-368-3169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-12
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3863G1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL3863GOtherALABAMA BOARD OF SOCIAL WORK