Provider Demographics
NPI:1740975051
Name:JOHNSON, MBWANA MWAI SAMUEL (MS, CRC, CASAS)
Entity type:Individual
Prefix:
First Name:MBWANA
Middle Name:MWAI SAMUEL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MS, CRC, CASAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 11TH ST
Mailing Address - Street 2:
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14301-1201
Mailing Address - Country:US
Mailing Address - Phone:716-278-8110
Mailing Address - Fax:716-282-1238
Practice Address - Street 1:1001 11TH ST
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14301-1201
Practice Address - Country:US
Practice Address - Phone:716-278-8110
Practice Address - Fax:716-282-1238
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY28675101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)