Provider Demographics
NPI:1952665002
Name:JOHNSON, ROGER D (LCSW)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:D
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 1:112 PEARSON
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-4436
Mailing Address - Country:US
Mailing Address - Phone:501-315-4224
Mailing Address - Fax:501-778-0450
Practice Address - Street 1:112 PEARSON
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-4436
Practice Address - Country:US
Practice Address - Phone:501-315-4224
Practice Address - Fax:501-778-0450
Is Sole Proprietor?:No
Enumeration Date:2012-07-03
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR6516-M104100000X
101YM0800X
AR6516-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116378726Medicaid