Provider Demographics
NPI:1093992794
Name:JOHNSON, DEGOLIA MONZELLO (LMSW)
Entity type:Individual
Prefix:MRS
First Name:DEGOLIA
Middle Name:MONZELLO
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 S LINDA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1531
Mailing Address - Country:US
Mailing Address - Phone:208-761-3593
Mailing Address - Fax:
Practice Address - Street 1:921 S ORCHARD ST STE 101
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1916
Practice Address - Country:US
Practice Address - Phone:208-703-7357
Practice Address - Fax:208-712-6778
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-25840174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist