Provider Demographics
NPI:1447809355
Name:JOHNSON, BROOKE LARSON (LCSW)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:LARSON
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:ERIN
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2875 BARBARA LANE NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062
Mailing Address - Country:US
Mailing Address - Phone:770-726-9589
Mailing Address - Fax:
Practice Address - Street 1:738 WOODLAWN DRIVE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068
Practice Address - Country:US
Practice Address - Phone:770-726-9589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0071171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical