Provider Demographics
NPI:1033483946
Name:JOHNSON, KENNETH WAYNE I
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:WAYNE
Last Name:JOHNSON
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 STANWELL DR STE 220
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-4828
Mailing Address - Country:US
Mailing Address - Phone:925-363-5000
Mailing Address - Fax:
Practice Address - Street 1:2600 STANWELL DR STE 220
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-4828
Practice Address - Country:US
Practice Address - Phone:925-363-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-24
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)