Provider Demographics
NPI:1811710254
Name:JOHNSON, CHAD
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17818
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-7818
Mailing Address - Country:US
Mailing Address - Phone:503-363-2021
Mailing Address - Fax:
Practice Address - Street 1:565 UNION ST NE STE 105
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2416
Practice Address - Country:US
Practice Address - Phone:503-363-2021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24-CRM-3422175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist