Provider Demographics
NPI:1831564814
Name:JOHNSON, REGINALD (SCA-IT)
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:SCA-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7314 W BURLEIGH ST
Mailing Address - Street 2:APT 3
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1082
Mailing Address - Country:US
Mailing Address - Phone:414-447-7208
Mailing Address - Fax:
Practice Address - Street 1:3707 N RICHARDS ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-1673
Practice Address - Country:US
Practice Address - Phone:414-967-7006
Practice Address - Fax:414-967-7020
Is Sole Proprietor?:No
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16415-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1780850594Medicaid