Basic Information
| Provider Information | |||||||||
| NPI: | 1629485354 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1012 OBERLIN RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276051242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198727373 | ||||||||
| FaxNumber: | 9198723713 | ||||||||
| Practice Location | |||||||||
| Address1: | 1012 OBERLIN RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276051242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198727373 | ||||||||
| FaxNumber: | 9198723713 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2014 | ||||||||
| LastUpdateDate: | 07/17/2014 | ||||||||
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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 | 106H00000X | 1140 | NC | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.