Provider Demographics
NPI:1811223407
Name:JOHNSON, DAVID ALLEN (MSW, LSW, LCAC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ALLEN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MSW, LSW, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3176 LANCER ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-4408
Mailing Address - Country:US
Mailing Address - Phone:219-763-8847
Mailing Address - Fax:219-762-7318
Practice Address - Street 1:3176 LANCER ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-4408
Practice Address - Country:US
Practice Address - Phone:219-763-8847
Practice Address - Fax:219-762-7318
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-02
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87000461A101YA0400X
IN33007055A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)