Provider Demographics
NPI:1336468271
Name:ANDRA D. JOHNSON
Entity Type:Organization
Organization Name:ANDRA D. JOHNSON
Other - Org Name:FOUR RIVERS & ASSOCIATES LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDRA
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LISW, LCSW, LCAC
Authorized Official - Phone:216-798-1997
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:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-18
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH991842101YA0400X
IN87000438A101YA0400X
IN34005636A1041C0700X
OHI-00093581041C0700X
WI2972-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39628200 (-31/078)Medicaid