Provider Demographics
NPI:1184095556
Name:JOHNSON, SAMUEL LEE III (CAC, CCGC)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:LEE
Last Name:JOHNSON
Suffix:III
Gender:M
Credentials:CAC, CCGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2637
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70059-2637
Mailing Address - Country:US
Mailing Address - Phone:504-261-4976
Mailing Address - Fax:504-766-6792
Practice Address - Street 1:2439 MANHATTAN BLVD STE 102-4
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:LA
Practice Address - Zip Code:70058-5473
Practice Address - Country:US
Practice Address - Phone:504-261-4976
Practice Address - Fax:504-766-8457
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 171000000X, 171M00000X, 175T00000X, 225C00000X, 101Y00000X, 101YA0400X, 101YM0800X, 101YP1600X, 103TA0400X, 103TC1900X
LA010494439343900000X
LA5006101YP2500X
LA1603101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No251S00000XAgenciesCommunity/Behavioral Health
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No171000000XOther Service ProvidersMilitary Health Care Provider
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA461582868Other461582868