Provider Demographics
NPI:1174006266
Name:JOHNSON, ANDRA CAVEN (LSW)
Entity Type:Individual
Prefix:
First Name:ANDRA
Middle Name:CAVEN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3675 E 140TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-4548
Mailing Address - Country:US
Mailing Address - Phone:216-632-3022
Mailing Address - Fax:
Practice Address - Street 1:3958 BROWN PARK DR STE D
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026-1160
Practice Address - Country:US
Practice Address - Phone:510-201-0190
Practice Address - Fax:888-972-2903
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0032144104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHS0032144OtherMEDICAL LICENSE