Provider Demographics
NPI:1679202758
Name:JOHNSON, MARY ELIZABETH (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30131 BULVERDE LN UNIT 371
Mailing Address - Street 2:
Mailing Address - City:BULVERDE
Mailing Address - State:TX
Mailing Address - Zip Code:78163-8821
Mailing Address - Country:US
Mailing Address - Phone:602-300-7302
Mailing Address - Fax:
Practice Address - Street 1:1329 AMMON PARK DR
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-4591
Practice Address - Country:US
Practice Address - Phone:208-403-0135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65860104100000X
ID8911068104100000X
AZLMSW-16316104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker