Provider Demographics
NPI:1790398568
Name:JOHNSON, SCOTTY A JR
Entity Type:Individual
Prefix:
First Name:SCOTTY
Middle Name:A
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 SE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-1704
Mailing Address - Country:US
Mailing Address - Phone:503-498-0557
Mailing Address - Fax:
Practice Address - Street 1:738 NE DAVIS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2931
Practice Address - Country:US
Practice Address - Phone:503-233-6090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker