Provider Demographics
NPI:1093787426
Name:JOHNSON, ANDRA D (LISW, LCSW, LCAC)
Entity Type:Individual
Prefix:MRS
First Name:ANDRA
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LISW, LCSW, LCAC
Other - Prefix:MRS
Other - First Name:ANDRA
Other - Middle Name:D
Other - Last Name:RIVERS-JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSSA
Mailing Address - Street 1:11014 CONSTANTIA CV
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:IN
Mailing Address - Zip Code:46783-8910
Mailing Address - Country:US
Mailing Address - Phone:216-798-1997
Mailing Address - Fax:260-672-0859
Practice Address - Street 1:4656 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 285
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6857
Practice Address - Country:US
Practice Address - Phone:260-422-9372
Practice Address - Fax:260-672-0859
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH991842 (LICDC)101YA0400X
OHI - 0009358 (LISW)1041C0700X
WI2979-123 (LCSW)1041C0700X
IN34005636A (LCSW)1041C0700X
IN87000438A (LCAC)101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39628200 -31/078Medicaid