Provider Demographics
NPI:1184056731
Name:JOHNSON, BECKY LOUISE (LCSW)
Entity type:Individual
Prefix:MS
First Name:BECKY
Middle Name:LOUISE
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 1:1365 ALPINE WAY
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-5392
Mailing Address - Country:US
Mailing Address - Phone:801-494-3128
Mailing Address - Fax:
Practice Address - Street 1:860 E 4500 S
Practice Address - Street 2:SUITE 302
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-3002
Practice Address - Country:US
Practice Address - Phone:801-494-3128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-06
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT373569-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical