Provider Demographics
NPI:1114363140
Name:JOHNSON, CAROL MARTIN (MA, ATR-BC, LPC)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:MARTIN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, ATR-BC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 SPRUCE ST UNIT 502
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-4372
Mailing Address - Country:US
Mailing Address - Phone:267-608-5354
Mailing Address - Fax:
Practice Address - Street 1:4919 PENTRIDGE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-3320
Practice Address - Country:US
Practice Address - Phone:267-608-5354
Practice Address - Fax:610-387-6056
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-16
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA004304101YP2500X
PARN264361L163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No163W00000XNursing Service ProvidersRegistered Nurse