Provider Demographics
NPI:1568072858
Name:JOHNSON, COLTEN LEWIS
Entity Type:Individual
Prefix:
First Name:COLTEN
Middle Name:LEWIS
Last Name:JOHNSON
Suffix:
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:PO BOX 3255
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-3255
Mailing Address - Country:US
Mailing Address - Phone:907-460-4992
Mailing Address - Fax:
Practice Address - Street 1:51310 TIMBER BAY COURT
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603
Practice Address - Country:US
Practice Address - Phone:907-373-4732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)