Provider Demographics
NPI:1447749056
Name:JOHNSON, CLYDE III
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:
Last Name:JOHNSON
Suffix:III
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 1:2525 TILLER LN STE 110
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231-2267
Mailing Address - Country:US
Mailing Address - Phone:614-305-5151
Mailing Address - Fax:614-283-5084
Practice Address - Street 1:2525 TILLER LANE STE 110
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231
Practice Address - Country:US
Practice Address - Phone:614-305-5151
Practice Address - Fax:614-283-5084
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health