Provider Demographics
NPI:1770271793
Name:JOHNSON, VIDAL JR (VIDAL JOHNSON)
Entity type:Individual
Prefix:MR
First Name:VIDAL
Middle Name:
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:VIDAL JOHNSON
Other - Prefix:MR
Other - First Name:VIDAL
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:CSW, DSP
Mailing Address - Street 1:9005 BREEZEWOOD TER APT 102
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-1055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9005 BREEZEWOOD TER APT 102
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-1055
Practice Address - Country:US
Practice Address - Phone:769-258-1534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health