Provider Demographics
NPI:1194407296
Name:JOHNSON, KATELYN SARA (LCSWA, MSW)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:SARA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSWA, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2544 WEDDINGTON AVE APT 2205
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-1002
Mailing Address - Country:US
Mailing Address - Phone:732-637-7540
Mailing Address - Fax:
Practice Address - Street 1:603 COX RD STE B
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-3432
Practice Address - Country:US
Practice Address - Phone:704-864-8046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0195531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical