Provider Demographics
NPI:1194198721
Name:JOHNSON, DALLAS EUGENE JR (LCMHC)
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:EUGENE
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 THORNECLIFFE DR
Mailing Address - Street 2:
Mailing Address - City:STATE ROAD
Mailing Address - State:NC
Mailing Address - Zip Code:28676-9263
Mailing Address - Country:US
Mailing Address - Phone:336-466-5381
Mailing Address - Fax:
Practice Address - Street 1:14072 ELKIN HIGHWAY 268
Practice Address - Street 2:
Practice Address - City:RONDA
Practice Address - State:NC
Practice Address - Zip Code:28670-9199
Practice Address - Country:US
Practice Address - Phone:336-827-0089
Practice Address - Fax:844-676-0500
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11973101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health