Provider Demographics
NPI:1174809669
Name:JOHNSON, DESWOOD JR (BSW)
Entity type:Individual
Prefix:MR
First Name:DESWOOD
Middle Name:
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 S FLORENCE ST TRLR 48
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-6763
Mailing Address - Country:US
Mailing Address - Phone:505-905-0061
Mailing Address - Fax:505-905-0064
Practice Address - Street 1:BLDG # T004-006 05 MILES EAST OF 371
Practice Address - Street 2:
Practice Address - City:THOREAU
Practice Address - State:NM
Practice Address - Zip Code:87323
Practice Address - Country:US
Practice Address - Phone:505-905-0062
Practice Address - Fax:505-905-0064
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM860092335OtherNAVAJO NATION