Provider Demographics
NPI:1609377431
Name:JOHNSON, RODERIC KENNETH (CDCA)
Entity Type:Individual
Prefix:MR
First Name:RODERIC
Middle Name:KENNETH
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3622 PROSPECT AVE E
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-2704
Mailing Address - Country:US
Mailing Address - Phone:216-508-6649
Mailing Address - Fax:216-431-4601
Practice Address - Street 1:22639 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44117-1622
Practice Address - Country:US
Practice Address - Phone:216-404-1900
Practice Address - Fax:216-404-1901
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH165698101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)