Provider Demographics
NPI:1356617211
Name:JOHNSON, LISA E (LCSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:E
Last Name:JOHNSON
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 1:155 CALLE PORTAL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2900
Mailing Address - Country:US
Mailing Address - Phone:520-459-3011
Mailing Address - Fax:520-515-8663
Practice Address - Street 1:108 ARIZONA ST
Practice Address - Street 2:
Practice Address - City:BISBEE
Practice Address - State:AZ
Practice Address - Zip Code:85603-1804
Practice Address - Country:US
Practice Address - Phone:520-432-3309
Practice Address - Fax:520-432-3717
Is Sole Proprietor?:No
Enumeration Date:2012-03-26
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0086461041C0700X
AZ164631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC008646OtherSTATE LICENSE