Provider Demographics
NPI:1487339818
Name:JOHNSON, KATHY LA RUE
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:LA RUE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 ASPEN DR APT B
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27409-3143
Mailing Address - Country:US
Mailing Address - Phone:336-987-5794
Mailing Address - Fax:
Practice Address - Street 1:10 ASPEN DR APT B
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27409-3143
Practice Address - Country:US
Practice Address - Phone:336-987-5794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health