Provider Demographics
NPI:1598006827
Name:JOHNSON, CHARLES DUSTIN (MS, EDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DUSTIN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MS, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 BUTTE PASS DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-3569
Mailing Address - Country:US
Mailing Address - Phone:970-444-2815
Mailing Address - Fax:
Practice Address - Street 1:2625 REDWING RD STE 110
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-2878
Practice Address - Country:US
Practice Address - Phone:970-444-2815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-12
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC0011971101Y00000X, 101YA0400X, 101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional