Basic Information
| Provider Information | |||||||||
| NPI: | 1083633481 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | JOY | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9615 E 148TH ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460604360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175870500 | ||||||||
| FaxNumber: | 3176740060 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 RANSDELL RD | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460522349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175741254 | ||||||||
| FaxNumber: | 3176740060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 12/09/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | 34005334A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 100270530A | 05 | IN | MEDICAID |