Provider Demographics
NPI:1285760330
Name:JOHNSON, CAROLE ELIZABETH (RN, CS, LICSW)
Entity type:Individual
Prefix:MS
First Name:CAROLE
Middle Name:ELIZABETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN, CS, LICSW
Other - Prefix:
Other - First Name:CAROLE
Other - Middle Name:ELIZABETH
Other - Last Name:JOHNSON-TUKES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN, CS, LICSW
Mailing Address - Street 1:9905 MAPLE LEAF DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886-1133
Mailing Address - Country:US
Mailing Address - Phone:301-258-2765
Mailing Address - Fax:301-740-3577
Practice Address - Street 1:15 E DEER PARK DR
Practice Address - Street 2:SUITE 101B
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2000
Practice Address - Country:US
Practice Address - Phone:301-881-4884
Practice Address - Fax:301-740-3577
Is Sole Proprietor?:No
Enumeration Date:2007-02-25
Last Update Date:2007-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR084348364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC705480Medicare ID - Type Unspecified