Provider Demographics
NPI:1033630033
Name:JOHNSON, SCOTT CHARLES (LAC RADT-1)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:CHARLES
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LAC RADT-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40853 CECINA WAY
Mailing Address - Street 2:
Mailing Address - City:BERMUDA DUNES
Mailing Address - State:CA
Mailing Address - Zip Code:92203-1171
Mailing Address - Country:US
Mailing Address - Phone:1760-406-3646
Mailing Address - Fax:
Practice Address - Street 1:40853 CECINA WAY
Practice Address - Street 2:
Practice Address - City:BERMUDA DUNES
Practice Address - State:CA
Practice Address - Zip Code:92203-1171
Practice Address - Country:US
Practice Address - Phone:1760-406-3646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1305101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)