Provider Demographics
NPI:1770513962
Name:JOHNSON, SUEZAN L (LCSW)
Entity type:Individual
Prefix:MS
First Name:SUEZAN
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 W 100 N STE 210
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9826
Mailing Address - Country:US
Mailing Address - Phone:435-755-6061
Mailing Address - Fax:435-994-8362
Practice Address - Street 1:1515 N 400 E STE 104
Practice Address - Street 2:
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-7595
Practice Address - Country:US
Practice Address - Phone:435-755-6061
Practice Address - Fax:435-755-6091
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT126457-3501104100000X
IDLCSW-39191104100000X, 1041C0700X
UT12645735011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker