Provider Demographics
NPI:1346015070
Name:JOHNSON, ELIJAH
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 CRESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HUXLEY
Mailing Address - State:IA
Mailing Address - Zip Code:50124-9479
Mailing Address - Country:US
Mailing Address - Phone:515-777-5818
Mailing Address - Fax:
Practice Address - Street 1:227 NW SCHOOL ST
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-1746
Practice Address - Country:US
Practice Address - Phone:515-225-4006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA120715101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health