Provider Demographics
NPI:1073973582
Name:JOHNSON, REILLY (CADC-I)
Entity Type:Individual
Prefix:
First Name:REILLY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CADC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 W MISSION ST
Mailing Address - Street 2:100
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95110-1713
Mailing Address - Country:US
Mailing Address - Phone:408-535-4002
Mailing Address - Fax:408-280-7201
Practice Address - Street 1:151 W MISSION ST
Practice Address - Street 2:100
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95110-1713
Practice Address - Country:US
Practice Address - Phone:408-535-4002
Practice Address - Fax:408-280-7201
Is Sole Proprietor?:No
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACI5201215101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACI5201215OtherCCAPP