Provider Demographics
NPI:1336341718
Name:JOHNSON, PEGGY WALTON (MA LSW)
Entity Type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:WALTON
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:971 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241
Mailing Address - Country:US
Mailing Address - Phone:304-636-9450
Mailing Address - Fax:304-636-7057
Practice Address - Street 1:971 HARRISON AVE
Practice Address - Street 2:YOUTH HEALTH SERVICE INC
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241
Practice Address - Country:US
Practice Address - Phone:304-636-9450
Practice Address - Fax:304-636-7057
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AP00451270104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0023397001Medicaid