Provider Demographics
NPI:1366421299
Name:JOHNSON, SHARON RENA (LCSW)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:RENA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6934 WELL SPRING RD
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-4027
Mailing Address - Country:US
Mailing Address - Phone:801-561-0465
Mailing Address - Fax:
Practice Address - Street 1:5965 S 900 E
Practice Address - Street 2:#240
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-1720
Practice Address - Country:US
Practice Address - Phone:801-263-7225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT497021235011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT827406OtherBLUE CROSS
UT9429838348OtherCHAMPUS
UT942938348SHAOtherEDUCATORS MUTUAL
UT107025298101OtherINTERMTN. HEALTH CARE
UTQ10330Medicare ID - Type UnspecifiedMEDICARE ADVANTAGE PLANS
UT827406OtherBLUE CROSS
UT002200235Medicare PIN
UT942938348SHAOtherEDUCATORS MUTUAL