Provider Demographics
NPI:1336234822
Name:JOHNSON, JUDITH L (LCSW, LPC)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 LOYOLA RD
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-6022
Mailing Address - Country:US
Mailing Address - Phone:573-803-7892
Mailing Address - Fax:904-797-2723
Practice Address - Street 1:104 LOYOLA RD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-6022
Practice Address - Country:US
Practice Address - Phone:573-803-7892
Practice Address - Fax:904-797-2723
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW117151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493292817Medicaid
MO000077091Medicare ID - Type Unspecified