Provider Demographics
NPI:1720032758
Name:JOHNSON, ILA B
Entity Type:Individual
Prefix:DR
First Name:ILA
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5010 MAYFIELD RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2611
Mailing Address - Country:US
Mailing Address - Phone:216-291-1550
Mailing Address - Fax:
Practice Address - Street 1:5010 MAYFIELD RD
Practice Address - Street 2:SUITE 103
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44124-2611
Practice Address - Country:US
Practice Address - Phone:216-291-1550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH321103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000116299OtherANTHEM BC/BS
OH0241796Medicaid
OH000000116299OtherANTHEM BC/BS