Provider Demographics
NPI:1689821720
Name:JOHNSON, TIMOTHY (LCSWA, LCAS, CSI)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LCSWA, LCAS, CSI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3433 STONEY GARDEN DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-1230
Mailing Address - Country:US
Mailing Address - Phone:980-253-1924
Mailing Address - Fax:
Practice Address - Street 1:236 LEPHILLIP COURT
Practice Address - Street 2:SUITE E
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025
Practice Address - Country:US
Practice Address - Phone:704-787-6751
Practice Address - Fax:704-721-5301
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-20437101YA0400X
NCP0047041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)