Provider Demographics
NPI:1396012514
Name:JOHNSON, WESLEY DAVID (CCDC II)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CCDC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 SOUTH ST STE 208
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:57701
Mailing Address - Country:US
Mailing Address - Phone:605-391-3482
Mailing Address - Fax:605-342-8144
Practice Address - Street 1:809 SOUTH ST STE 208
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-3583
Practice Address - Country:US
Practice Address - Phone:605-391-3482
Practice Address - Fax:605-342-8144
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD08051365101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)