Provider Demographics
NPI:1255698205
Name:JOHNSON, SCOTT KENNETH (MSW, LICSW, LCSW)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:KENNETH
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MSW, LICSW, 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 631
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-0631
Mailing Address - Country:US
Mailing Address - Phone:715-575-4322
Mailing Address - Fax:
Practice Address - Street 1:1411 ELLIS AVENUE
Practice Address - Street 2:MEAD HALL ROOM 135
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806
Practice Address - Country:US
Practice Address - Phone:715-575-4322
Practice Address - Fax:855-702-1966
Is Sole Proprietor?:No
Enumeration Date:2012-04-16
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN210821041C0700X
WI84731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1255698205Medicaid
MN1255698205Medicaid