Provider Demographics
NPI:1194739359
Name:JOHNSON, JUDITH CAVENAUGH (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:CAVENAUGH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 LIMESTONE RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:KENANSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28349-9019
Mailing Address - Country:US
Mailing Address - Phone:910-296-0082
Mailing Address - Fax:
Practice Address - Street 1:149 LIMESTONE RD
Practice Address - Street 2:SUITE 4
Practice Address - City:KENANSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28349-9019
Practice Address - Country:US
Practice Address - Phone:910-296-0082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0039881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002377Medicaid