Provider Demographics
NPI:1790023950
Name:JOHNSON, PAMELA (LAC)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 GREGG HWY
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-6341
Mailing Address - Country:US
Mailing Address - Phone:803-649-1900
Mailing Address - Fax:803-643-2926
Practice Address - Street 1:1105 GREGG HWY
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801
Practice Address - Country:US
Practice Address - Phone:803-649-1900
Practice Address - Fax:803-643-2926
Is Sole Proprietor?:No
Enumeration Date:2013-01-23
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC570569761OtherTAX ID
SCAD01AKMedicaid