Provider Demographics
NPI:1962658658
Name:JOHNSON, MARY V (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:V
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:VICKIE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:245 NW HARWOOD ST
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-1445
Mailing Address - Country:US
Mailing Address - Phone:541-647-7707
Mailing Address - Fax:
Practice Address - Street 1:1221 ABRAMS RD
Practice Address - Street 2:236
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75081-5578
Practice Address - Country:US
Practice Address - Phone:214-604-7650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-13
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR33041041C0700X
TX557081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR3304OtherLCSW
OR3304OtherLCSW