Provider Demographics
NPI:1336343045
Name:JOHNSON, CICELY
Entity Type:Individual
Prefix:
First Name:CICELY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1729 FOREST COVE DR APT 306
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-5488
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:77 W WASHINGTON ST
Practice Address - Street 2:SUITE
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-2801
Practice Address - Country:US
Practice Address - Phone:312-823-8600
Practice Address - Fax:312-823-8600
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0122181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical