Provider Demographics
NPI:1821646779
Name:JOHNSON, ELIZABETH A (BA, CADC, CODP)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BA, CADC, CODP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MARTIN CT
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60411-4610
Mailing Address - Country:US
Mailing Address - Phone:708-663-5779
Mailing Address - Fax:
Practice Address - Street 1:1 MARTIN CT
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60411-4610
Practice Address - Country:US
Practice Address - Phone:708-663-5779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-03
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL20863101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILJ52522163814OtherDRIVERS LICENSE