Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | CSW003882 | GA |
NPI | 1003072364 |
---|---|
Provider Name | Michael Kendrick Johnson |
First Address | Atlanta, GA 30309-4282 |
Second Address | Atlanta, GA 30309-4282 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/08/2008 |
Last Update Date | 30/01/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
316564733A | (05) | GA |