Provider Demographics
NPI:1548489339
Name:JOHNSON, MARK (LISW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5611 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-4043
Mailing Address - Country:US
Mailing Address - Phone:330-653-8630
Mailing Address - Fax:
Practice Address - Street 1:24200 CHAGRIN BLVD
Practice Address - Street 2:THE OFFICE PLACE
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5550
Practice Address - Country:US
Practice Address - Phone:216-831-6466
Practice Address - Fax:216-766-6084
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI0007583104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
JOSW25931Medicare ID - Type Unspecified