Provider Demographics
NPI:1558016055
Name:JOHNSON, ANNIE R (LCADC)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-1960
Mailing Address - Country:US
Mailing Address - Phone:862-668-6149
Mailing Address - Fax:
Practice Address - Street 1:300 S 12TH ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-1960
Practice Address - Country:US
Practice Address - Phone:973-622-4934
Practice Address - Fax:973-622-5820
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LCOOO63500101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)