Provider Demographics
NPI:1457854044
Name:REDD JOHNSON, CODY WILLIAM (LPC, NCC)
Entity Type:Individual
Prefix:MR
First Name:CODY
Middle Name:WILLIAM
Last Name:REDD JOHNSON
Suffix:
Gender:M
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83653-0009
Mailing Address - Country:US
Mailing Address - Phone:208-467-4431
Mailing Address - Fax:208-467-7684
Practice Address - Street 1:156 MCCLURE AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-2025
Practice Address - Country:US
Practice Address - Phone:208-323-9600
Practice Address - Fax:208-466-5359
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-09
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-10144101Y00000X
IDLPC-6773101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLPC-6773Medicaid