Provider Demographics
NPI:1396523437
Name:JOHNSON, MATTHEW (LPC-IT, SAC-IT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LPC-IT, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W168N9096 GARDEN AVE
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-2114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1622 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-3014
Practice Address - Country:US
Practice Address - Phone:262-306-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20000-130101YA0400X
WI7352-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)