Provider Demographics
NPI:1982844973
Name:JOHNSON, CYNTHIA
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10625 S MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-2707
Mailing Address - Country:US
Mailing Address - Phone:773-928-1109
Mailing Address - Fax:773-928-2099
Practice Address - Street 1:10625 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-2707
Practice Address - Country:US
Practice Address - Phone:773-928-1109
Practice Address - Fax:773-928-2099
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-03
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 251C00000X
ILJ52510455820343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No251C00000XAgenciesDay Training, Developmentally Disabled Services