Provider Demographics
NPI:1043254493
Name:JOHNSON, ERIC (LCPC)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-5742
Mailing Address - Country:US
Mailing Address - Phone:207-775-1335
Mailing Address - Fax:
Practice Address - Street 1:205 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-5742
Practice Address - Country:US
Practice Address - Phone:207-775-1335
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC3012104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME100210OtherBC/BS