Provider Demographics
NPI:1740993666
Name:JOHNSON, SHAUN (LCADC)
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 LONGWORTH ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-1233
Mailing Address - Country:US
Mailing Address - Phone:973-449-6807
Mailing Address - Fax:
Practice Address - Street 1:26 LONGWORTH ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-1233
Practice Address - Country:US
Practice Address - Phone:973-449-6807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)