Provider Demographics
NPI:1023558681
Name:MARCUM, JOHNNY R (CDCA/CPRS/QMHS3)
Entity type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:R
Last Name:MARCUM
Suffix:
Gender:M
Credentials:CDCA/CPRS/QMHS3
Other - Prefix:MR
Other - First Name:JOHNNY
Other - Middle Name:R
Other - Last Name:MARCUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CDCA/CPRS/QMHS3
Mailing Address - Street 1:1045 WALTON AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-5336
Mailing Address - Country:US
Mailing Address - Phone:937-496-5250
Mailing Address - Fax:
Practice Address - Street 1:3501 E LIVINGSTON AVE STE A
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43227-2220
Practice Address - Country:US
Practice Address - Phone:937-496-5250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-02
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH185253101YA0400X, 171M00000X
OH004481171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)