Provider Demographics
NPI:1720174022
Name:JOHNSON, AMY LYNN-SMITH (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:LYNN-SMITH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4948 GRAYS CREEK CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-7810
Mailing Address - Country:US
Mailing Address - Phone:910-850-2095
Mailing Address - Fax:
Practice Address - Street 1:581 EXECUTIVE PL
Practice Address - Street 2:SUITE 500
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5702
Practice Address - Country:US
Practice Address - Phone:910-493-3555
Practice Address - Fax:910-493-3520
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2016-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC005604101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106625Medicaid