Provider Demographics
NPI:1942656244
Name:JOHNSON, SHIRLEY ANN (OHIO LICDC-CSAND LSW)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OHIO LICDC-CSAND LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8658 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1328
Mailing Address - Country:US
Mailing Address - Phone:937-701-0030
Mailing Address - Fax:937-387-9043
Practice Address - Street 1:8658 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1328
Practice Address - Country:US
Practice Address - Phone:937-701-0030
Practice Address - Fax:937-387-9043
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC-CS 933508207QA0401X
OHLSW S0021857207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH436030Medicare PIN