Provider Demographics
NPI:1689219297
Name:JOHNSON, THOMAS (CDCA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4342 GALLIA ST STE A
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-5563
Mailing Address - Country:US
Mailing Address - Phone:740-529-1184
Mailing Address - Fax:
Practice Address - Street 1:4342 GALLIA ST STE A
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-5563
Practice Address - Country:US
Practice Address - Phone:740-529-1184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.172043101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)