Provider Demographics
NPI:1902141013
Name:JOHANSON, KATHRYN CASEY (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:CASEY
Last Name:JOHANSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:CASEY
Other - Last Name:JOHANSON-PAPA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 602658
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2658
Mailing Address - Country:US
Mailing Address - Phone:336-713-7493
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-713-7493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0054611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical