Provider Demographics
NPI:1730509175
Name:JOHNSON, MARCIA
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:
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 1:2610 N SILVER ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-7299
Mailing Address - Country:US
Mailing Address - Phone:575-388-9374
Mailing Address - Fax:575-388-4847
Practice Address - Street 1:2610 N SILVER ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-7299
Practice Address - Country:US
Practice Address - Phone:575-388-9374
Practice Address - Fax:575-388-4847
Is Sole Proprietor?:No
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMB-4011104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker