Provider Demographics
NPI:1619416054
Name:CAROL MARTIN JOHNSON LLC
Entity type:Organization
Organization Name:CAROL MARTIN JOHNSON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:ATR-BC, LPC
Authorized Official - Phone:267-608-5354
Mailing Address - Street 1:4708 KINGSESSING AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-3819
Mailing Address - Country:US
Mailing Address - Phone:267-608-5354
Mailing Address - Fax:
Practice Address - Street 1:8600 W CHESTER PIKE
Practice Address - Street 2:SUITE 108
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-2629
Practice Address - Country:US
Practice Address - Phone:610-387-6056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC004304101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty