Provider Demographics
NPI:1578859963
Name:JOHNSON, KLARICE ANN (LCSW)
Entity type:Individual
Prefix:
First Name:KLARICE
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KLARICE
Other - Middle Name:ANN
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSCW
Mailing Address - Street 1:734 N HIGHWAY 91
Mailing Address - Street 2:
Mailing Address - City:FIRTH
Mailing Address - State:ID
Mailing Address - Zip Code:83236-1156
Mailing Address - Country:US
Mailing Address - Phone:208-757-2932
Mailing Address - Fax:
Practice Address - Street 1:518 N STATE ST
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-1113
Practice Address - Country:US
Practice Address - Phone:208-557-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2023-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-366221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1881708832Medicaid