Provider Demographics
NPI:1861923062
Name:JOHNSON, FORMKA (LCSW-C)
Entity type:Individual
Prefix:
First Name:FORMKA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 E PRESTON ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-5621
Mailing Address - Country:US
Mailing Address - Phone:443-991-1370
Mailing Address - Fax:
Practice Address - Street 1:1 E CHASE ST STE 1108
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2564
Practice Address - Country:US
Practice Address - Phone:443-991-1370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22602104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker