Provider Demographics
NPI:1639742273
Name:JOHNSON, ESLIE THOMAS (PRS, CDCA)
Entity Type:Individual
Prefix:
First Name:ESLIE
Middle Name:THOMAS
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PRS, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44301-1664
Mailing Address - Country:US
Mailing Address - Phone:330-644-4095
Mailing Address - Fax:330-644-2031
Practice Address - Street 1:3445 S MAIN ST
Practice Address - Street 2:
Practice Address - City:COVENTRY TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:44319-3028
Practice Address - Country:US
Practice Address - Phone:330-644-4095
Practice Address - Fax:330-644-2031
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.000798175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0452494Medicaid