Provider Demographics
NPI:1841517646
Name:JOHNSON, JOHNNY JR (LCSW)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15627 NORMANS LANDING DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-7126
Mailing Address - Country:US
Mailing Address - Phone:980-395-7001
Mailing Address - Fax:
Practice Address - Street 1:1552 UNION RD
Practice Address - Street 2:SUITE E
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5523
Practice Address - Country:US
Practice Address - Phone:704-833-0154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0068541041C0700X, 101YM0800X, 101YP2500X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007680Medicaid