Provider Demographics
NPI:1932398393
Name:JOHNSON, BRUCE DAVID (LCSW)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
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:PO BOX 2949
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-2949
Mailing Address - Country:US
Mailing Address - Phone:907-260-7300
Mailing Address - Fax:907-260-7301
Practice Address - Street 1:230 EAST MARYDALE
Practice Address - Street 2:SUITE 2
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7648
Practice Address - Country:US
Practice Address - Phone:907-260-3691
Practice Address - Fax:907-260-7301
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKFH177FQMedicaid
AKMH0150Medicaid
AKMH0156Medicaid
AKMH0150Medicaid
AKFH177FQMedicaid
AKFH177FQMedicare UPIN