Provider Demographics
NPI:1962782144
Name:JOHNSON, LUCILLE D (MSW)
Entity type:Individual
Prefix:
First Name:LUCILLE
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 KANAKANAK ROAD
Mailing Address - Street 2:
Mailing Address - City:DILLINGHAM
Mailing Address - State:AK
Mailing Address - Zip Code:99576-0310
Mailing Address - Country:US
Mailing Address - Phone:907-842-4139
Mailing Address - Fax:907-842-4106
Practice Address - Street 1:1500 KANAKANAK ROAD
Practice Address - Street 2:
Practice Address - City:DILLINGHAM
Practice Address - State:AK
Practice Address - Zip Code:99576-0310
Practice Address - Country:US
Practice Address - Phone:907-842-4139
Practice Address - Fax:907-842-4106
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM9470Medicaid