Provider Demographics
NPI:1619246063
Name:JOHNSON, AMANDA ROXANNE (CHA-III)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROXANNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CHA-III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 BACK STREET
Mailing Address - Street 2:
Mailing Address - City:SHUNGNAK
Mailing Address - State:AK
Mailing Address - Zip Code:99773
Mailing Address - Country:US
Mailing Address - Phone:907-437-2138
Mailing Address - Fax:907-437-2139
Practice Address - Street 1:110 MAIN STREET
Practice Address - Street 2:
Practice Address - City:AMBLER
Practice Address - State:AK
Practice Address - Zip Code:99786-0110
Practice Address - Country:US
Practice Address - Phone:907-445-2129
Practice Address - Fax:907-445-2179
Is Sole Proprietor?:No
Enumeration Date:2011-12-14
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
AK11-1129-II172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172V00000XOther Service ProvidersCommunity Health Worker