Provider Demographics
NPI:1659438752
Name:JOHNSON, CORANDLE (LPC)
Entity Type:Individual
Prefix:MR
First Name:CORANDLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:MR
Other - First Name:CORANDLE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 1181
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-1181
Mailing Address - Country:US
Mailing Address - Phone:706-315-9040
Mailing Address - Fax:334-448-8836
Practice Address - Street 1:83 US HIGHWAY 169 NORTH
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36870-8552
Practice Address - Country:US
Practice Address - Phone:706-315-9040
Practice Address - Fax:334-448-8836
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2240101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional