Provider Demographics
NPI:1992217855
Name:JOHNSON, BRENDA KAY (CCHW)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:KAY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CCHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 S ARCH AVE
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-4202
Mailing Address - Country:US
Mailing Address - Phone:330-596-7591
Mailing Address - Fax:
Practice Address - Street 1:1401 S ARCH AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-4202
Practice Address - Country:US
Practice Address - Phone:330-596-7591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCHW000717172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty