Provider Demographics
NPI:1437463742
Name:JOHNSON, TIMOTHY LEE (MA, LCAS)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MA, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 RHETT CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-3660
Mailing Address - Country:US
Mailing Address - Phone:704-579-0427
Mailing Address - Fax:
Practice Address - Street 1:3100 RHETT CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-3660
Practice Address - Country:US
Practice Address - Phone:704-579-0427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS 1659101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6112183Medicaid