Provider Demographics
NPI:1730253014
Name:JOHNSON, GWENDOLYN WATTS (LCSWC)
Entity type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:WATTS
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LCSWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1425 LIBERTY ROAD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784
Mailing Address - Country:US
Mailing Address - Phone:410-552-0773
Mailing Address - Fax:410-552-0774
Practice Address - Street 1:9199 REISTERSTOWN ROAD
Practice Address - Street 2:SUITE 214C
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117
Practice Address - Country:US
Practice Address - Phone:410-552-0773
Practice Address - Fax:410-552-0774
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD043931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical