Provider Demographics
NPI:1679368476
Name:JOHNSON, LATIA (LCSW)
Entity type:Individual
Prefix:
First Name:LATIA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 ELM PL
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-5340
Mailing Address - Country:US
Mailing Address - Phone:518-727-2735
Mailing Address - Fax:
Practice Address - Street 1:530 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12305-2014
Practice Address - Country:US
Practice Address - Phone:518-370-8124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-11
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0915091041C0700X, 1041S0200X
1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical