Provider Demographics
NPI:1750521449
Name:JOHNSON, STEPHANIE MAE (LCSW)
Entity type:Individual
Prefix:MISS
First Name:STEPHANIE
Middle Name:MAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:STEPHANIE
Other - Middle Name:MAE
Other - Last Name:LIVELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:25 JEFFERSON WAY
Mailing Address - Street 2:STE 102
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901
Mailing Address - Country:US
Mailing Address - Phone:907-247-7827
Mailing Address - Fax:973-215-2052
Practice Address - Street 1:25 JEFFERSON WAY
Practice Address - Street 2:STE 102
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901
Practice Address - Country:US
Practice Address - Phone:907-247-7827
Practice Address - Fax:973-215-2052
Is Sole Proprietor?:No
Enumeration Date:2009-02-20
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1579599Medicaid