Provider Demographics
NPI:1891191052
Name:JOHNSON, ANJALISSA D (ADT)
Entity Type:Individual
Prefix:
First Name:ANJALISSA
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8501 LASALLE RD,
Mailing Address - Street 2:SUITE 115
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-1712
Mailing Address - Country:US
Mailing Address - Phone:410-337-7772
Mailing Address - Fax:410-337-8729
Practice Address - Street 1:8501 LASALLE RD,
Practice Address - Street 2:SUITE 115
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286
Practice Address - Country:US
Practice Address - Phone:410-337-7772
Practice Address - Fax:410-337-8729
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-14
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDADT960101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)