Provider Demographics
NPI:1215221486
Name:JOHNSON, CANDACE S (PHD)
Entity Type:Individual
Prefix:DR
First Name:CANDACE
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6404 THORNBERRY CT
Mailing Address - Street 2:SUITE 430
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-3502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6404 THORNBERRY CT
Practice Address - Street 2:SUITE 430
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-3502
Practice Address - Country:US
Practice Address - Phone:513-229-7585
Practice Address - Fax:513-229-7731
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6619103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical