Provider Demographics
NPI:1467462325
Name:JOHNSON, ROSALYN A (LMFT)
Entity type:Individual
Prefix:
First Name:ROSALYN
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 N OAK ST
Mailing Address - Street 2:BUILDING B-3
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1744
Mailing Address - Country:US
Mailing Address - Phone:229-257-0100
Mailing Address - Fax:229-257-0050
Practice Address - Street 1:2704 N OAK ST
Practice Address - Street 2:BUILDING B-3
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1744
Practice Address - Country:US
Practice Address - Phone:229-257-0100
Practice Address - Fax:229-257-0050
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000965106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA466251661AMedicaid