Provider Demographics
NPI:1639376783
Name:ANTWI, JOHNSON (LCAS-A)
Entity Type:Individual
Prefix:
First Name:JOHNSON
Middle Name:
Last Name:ANTWI
Suffix:
Gender:M
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 STEWART PKWY
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-4972
Mailing Address - Country:US
Mailing Address - Phone:252-946-0585
Mailing Address - Fax:252-946-0580
Practice Address - Street 1:216 STEWART PKWY
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-4972
Practice Address - Country:US
Practice Address - Phone:252-946-0585
Practice Address - Fax:252-946-0580
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0157821041C0700X
NCLCAS-2605101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005782Medicaid