Provider Demographics
NPI:1891284717
Name:JOHNSON, AMANDA MARIE (LCDCII)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCDCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1899 LOWER BELLBROOK RD
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-9310
Mailing Address - Country:US
Mailing Address - Phone:937-613-9537
Mailing Address - Fax:
Practice Address - Street 1:1725 E 3RD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45403-1850
Practice Address - Country:US
Practice Address - Phone:937-387-6395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCII.161326103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)