1730253014 NPI number — MRS. GWENDOLYN WATTS JOHNSON LCSWC

Table of content: MRS. GWENDOLYN WATTS JOHNSON LCSWC (NPI 1730253014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730253014 NPI number — MRS. GWENDOLYN WATTS JOHNSON LCSWC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
GWENDOLYN
Provider Middle Name:
WATTS
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSWC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730253014
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1425 LIBERTY ROAD
Provider Second Line Business Mailing Address:
SUITE 208
Provider Business Mailing Address City Name:
ELDERSBURG
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21784
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-552-0773
Provider Business Mailing Address Fax Number:
410-552-0774

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9199 REISTERSTOWN ROAD
Provider Second Line Business Practice Location Address:
SUITE 214C
Provider Business Practice Location Address City Name:
OWINGS MILLS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-552-0773
Provider Business Practice Location Address Fax Number:
410-552-0774
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  04393 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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