Basic Information
| Provider Information | |||||||||
| NPI: | 1326419763 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | EARLENE | ||||||||
| MiddleName: | P. | ||||||||
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| Credential: | LISW-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9220 MENTOR AVENUE | ||||||||
| Address2: | BEACON HEALTH | ||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440606412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406393509 | ||||||||
| FaxNumber: | 4402051009 | ||||||||
| Practice Location | |||||||||
| Address1: | 9220 MENTOR AVENUE | ||||||||
| Address2: | BEACON HEALTH | ||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440606412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406393509 | ||||||||
| FaxNumber: | 4402051009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2015 | ||||||||
| LastUpdateDate: | 10/12/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | I.0007714-SUPV | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.