Provider Demographics
NPI:1396894259
Name:MARTIN-JOHNSON, CAROLYN M (LPC)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:M
Last Name:MARTIN-JOHNSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1499 SIXTH ST
Mailing Address - Street 2:INNOVATIVE COUNSELING, INC
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-2252
Mailing Address - Country:US
Mailing Address - Phone:920-497-6161
Mailing Address - Fax:920-498-0476
Practice Address - Street 1:1499 SIXTH ST
Practice Address - Street 2:INNOVATIVE COUNSELING, INC
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-2252
Practice Address - Country:US
Practice Address - Phone:920-497-6161
Practice Address - Fax:920-498-0476
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14160101YA0400X
WI4155-125104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40965400Medicaid