Provider Demographics
NPI:1942317474
Name:JOHNSON, CLARENCE (CADC III)
Entity Type:Individual
Prefix:MR
First Name:CLARENCE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CADC III
Other - Prefix:
Other - First Name:CLARENCE
Other - Middle Name:
Other - Last Name:REED
Other - Suffix:
Other - Last Name Type:Doing Business As
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:1220 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-2598
Practice Address - Country:US
Practice Address - Phone:414-454-6707
Practice Address - Fax:414-454-6747
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1876101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor