Provider Demographics
NPI:1124293980
Name:JOHNSON, GARY BRIAN (MSW)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:BRIAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4455 E 56TH ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807
Mailing Address - Country:US
Mailing Address - Phone:563-386-4004
Mailing Address - Fax:563-386-4026
Practice Address - Street 1:4455 E 56TH ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807
Practice Address - Country:US
Practice Address - Phone:563-386-4004
Practice Address - Fax:563-386-4026
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00923104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker