Basic Information
| Provider Information | |||||||||
| NPI: | 1356617211 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 155 CALLE PORTAL | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SIERRA VISTA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856352900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204593011 | ||||||||
| FaxNumber: | 5205158663 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 ARIZONA ST | ||||||||
| Address2: | |||||||||
| City: | BISBEE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856031804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204323309 | ||||||||
| FaxNumber: | 5204323717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2012 | ||||||||
| LastUpdateDate: | 12/06/2016 | ||||||||
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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 | 1041C0700X | C008646 | NC | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 16463 | AZ | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | C008646 | 01 | NC | STATE LICENSE | OTHER |