Provider Demographics
NPI:1336155357
Name:JOHNSON, NINA PAULINE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:NINA
Middle Name:PAULINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:POLLY
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:423 OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:HEWITT
Mailing Address - State:TX
Mailing Address - Zip Code:76643
Mailing Address - Country:US
Mailing Address - Phone:254-666-2300
Mailing Address - Fax:254-666-2300
Practice Address - Street 1:423 OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:HEWITT
Practice Address - State:TX
Practice Address - Zip Code:76643-3116
Practice Address - Country:US
Practice Address - Phone:254-666-2300
Practice Address - Fax:254-666-2300
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX286301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87395QOtherBLUE CROSS BLUE SHIELD
TX165675301Medicaid
TX063LVOtherBCBS
TX1656753-02Medicaid
TX165675301Medicaid
TX610767Medicare PIN