Provider Demographics
NPI:1477104511
Name:JOHNSON, Y. DIANA (MA, LCDC)
Entity Type:Individual
Prefix:
First Name:Y. DIANA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, LCDC
Other - Prefix:
Other - First Name:YOLANDA
Other - Middle Name:DIANA
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA LCDC
Mailing Address - Street 1:PO BOX 144031
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78714-4031
Mailing Address - Country:US
Mailing Address - Phone:512-910-5188
Mailing Address - Fax:
Practice Address - Street 1:7901 CAMERON RD STE 2-139
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78754-3802
Practice Address - Country:US
Practice Address - Phone:512-910-5188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2019-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15020101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)