Basic Information
| Provider Information | |||||||||
| NPI: | 1932398393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2949 | ||||||||
| Address2: | |||||||||
| City: | SOLDOTNA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996692949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072607300 | ||||||||
| FaxNumber: | 9072607301 | ||||||||
| Practice Location | |||||||||
| Address1: | 230 EAST MARYDALE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | SOLDOTNA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996697648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072603691 | ||||||||
| FaxNumber: | 9072607301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2007 | ||||||||
| LastUpdateDate: | 05/16/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | FH177FQ | 05 | AK | MEDICAID | MH0150 | 05 | AK | MEDICAID | MH0156 | 05 | AK | MEDICAID |