Provider Demographics
NPI:1871010967
Name:JOHNSON, NICOLE LYNN (CADC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 GALLIA ST.
Mailing Address - Street 2:SUITE 600
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2550 CARTER AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7830
Practice Address - Country:US
Practice Address - Phone:606-329-0727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.161508101YA0400X
KY281137101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)