Provider Demographics
NPI:1780121095
Name:JOHNSON, UTRENA
Entity type:Individual
Prefix:
First Name:UTRENA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 N DUNCAN BYP STE K
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:SC
Mailing Address - Zip Code:29379-8605
Mailing Address - Country:US
Mailing Address - Phone:864-466-5428
Mailing Address - Fax:
Practice Address - Street 1:719 N DUNCAN BYP STE K
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:SC
Practice Address - Zip Code:29379-8605
Practice Address - Country:US
Practice Address - Phone:864-466-5428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program