Provider Demographics
NPI:1962220657
Name:JOHNSON, MARY GRACE (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:GRACE
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 1:543 W THIRD ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40508-1259
Mailing Address - Country:US
Mailing Address - Phone:859-967-4453
Mailing Address - Fax:
Practice Address - Street 1:245 FOUNTAIN CT STE 225
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2794
Practice Address - Country:US
Practice Address - Phone:859-323-6021
Practice Address - Fax:859-323-1670
Is Sole Proprietor?:No
Enumeration Date:2024-10-01
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2594851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical