Provider Demographics
NPI:1588640700
Name:JOHNSON, MICHAEL ANTHONY (MSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MSW
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 1025
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25802-1025
Mailing Address - Country:US
Mailing Address - Phone:304-252-8409
Mailing Address - Fax:304-252-0022
Practice Address - Street 1:24 MALLARD CT
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3664
Practice Address - Country:US
Practice Address - Phone:304-252-8409
Practice Address - Fax:304-252-0022
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009390972084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0116688000Medicaid
WV0116688000Medicaid