Provider Demographics
NPI:1770549768
Name:JOHNSON, LARRY STEVEN (MSW, LCSW)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:STEVEN
Last Name:JOHNSON
Suffix:
Gender:M
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 1:149 HART ST
Mailing Address - Street 2:82 MEDICAL GROUP/CREDENTIALS
Mailing Address - City:SHEPPARD AFB
Mailing Address - State:TX
Mailing Address - Zip Code:76311-3477
Mailing Address - Country:US
Mailing Address - Phone:940-676-6075
Mailing Address - Fax:
Practice Address - Street 1:149 HART ST
Practice Address - Street 2:82 MEDICAL GROUP/CREDENTIALS
Practice Address - City:SHEPPARD AFB
Practice Address - State:TX
Practice Address - Zip Code:76311-3477
Practice Address - Country:US
Practice Address - Phone:940-676-6075
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS103611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXVAD 000Medicare UPIN