Provider Demographics
NPI:1780291500
Name:JOHNSON, TERESA MICHELLE
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:MICHELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 CHUB LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27574-8866
Mailing Address - Country:US
Mailing Address - Phone:919-225-3303
Mailing Address - Fax:
Practice Address - Street 1:2850 VIRGILINA RD
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27574-8226
Practice Address - Country:US
Practice Address - Phone:919-225-3303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)