Provider Demographics
NPI:1366825697
Name:JOHNSON, DAISHA (CDCA)
Entity Type:Individual
Prefix:
First Name:DAISHA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-1013
Mailing Address - Country:US
Mailing Address - Phone:419-222-4474
Mailing Address - Fax:419-222-7044
Practice Address - Street 1:809 W VINE ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-1054
Practice Address - Country:US
Practice Address - Phone:419-222-4474
Practice Address - Fax:419-222-7044
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-06
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1366825697101YA0400X
251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1366825697Medicaid
OH1366825697Medicare UPIN
OH1366825697Medicare NSC
OH1366825697Medicaid
OH1366825697Medicare PIN