Provider Demographics
NPI:1972753366
Name:JOHNSON, MINTA GARDYN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MINTA
Middle Name:GARDYN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1755 N COLLINS BLVD
Mailing Address - Street 2:SUITE 525
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3562
Mailing Address - Country:US
Mailing Address - Phone:214-369-5522
Mailing Address - Fax:214-369-5327
Practice Address - Street 1:1755 N COLLINS BLVD
Practice Address - Street 2:SUITE 525
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3562
Practice Address - Country:US
Practice Address - Phone:214-369-5522
Practice Address - Fax:214-369-5327
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-23
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX585401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical