Provider Demographics
NPI:1659600732
Name:JOHNSON, ANITA GAIL (MA)
Entity Type:Individual
Prefix:MISS
First Name:ANITA
Middle Name:GAIL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-3121
Mailing Address - Country:US
Mailing Address - Phone:410-383-7197
Mailing Address - Fax:410-383-3131
Practice Address - Street 1:1501 DIVISION ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-3121
Practice Address - Country:US
Practice Address - Phone:410-383-7197
Practice Address - Fax:410-483-3131
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-18
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC0722101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)