Provider Demographics
NPI:1932844404
Name:JOHNSON, CYNTHIA MARIE (PC-IT)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PC-IT
Other - Prefix:MS
Other - First Name:CYNTHIA
Other - Middle Name:MARIE
Other - Last Name:KLUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8010
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53547-8010
Mailing Address - Country:US
Mailing Address - Phone:608-757-0404
Mailing Address - Fax:608-757-2319
Practice Address - Street 1:1 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-3977
Practice Address - Country:US
Practice Address - Phone:608-757-0404
Practice Address - Fax:608-757-2319
Is Sole Proprietor?:No
Enumeration Date:2022-04-29
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10835-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional