Provider Demographics
NPI:1255347241
Name:JOHNSON-HARRIS, SANDRA ELLEN (LCSW)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:ELLEN
Last Name:JOHNSON-HARRIS
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:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:FINCASTLE
Mailing Address - State:VA
Mailing Address - Zip Code:24090-0098
Mailing Address - Country:US
Mailing Address - Phone:540-353-7231
Mailing Address - Fax:540-254-2937
Practice Address - Street 1:2728 COLONIAL AVE SW
Practice Address - Street 2:SUITE 117
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-3878
Practice Address - Country:US
Practice Address - Phone:540-353-7231
Practice Address - Fax:540-254-2937
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040027181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00891610Medicaid