Provider Demographics
NPI:1306668595
Name:JOHNSON, MIRANDA (LMSW)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3822 N PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-6286
Mailing Address - Country:US
Mailing Address - Phone:479-367-2866
Mailing Address - Fax:479-332-5356
Practice Address - Street 1:3822 N PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6286
Practice Address - Country:US
Practice Address - Phone:479-367-2866
Practice Address - Fax:479-332-5356
Is Sole Proprietor?:No
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR11557-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker