Provider Demographics
NPI:1912208646
Name:JOHNSON, TREVOR
Entity Type:Individual
Prefix:MR
First Name:TREVOR
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 1:4200 WESTFIELD DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-1838
Mailing Address - Country:US
Mailing Address - Phone:203-414-9306
Mailing Address - Fax:
Practice Address - Street 1:3575 MACON RD STE 731907
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-8200
Practice Address - Country:US
Practice Address - Phone:203-414-9306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-11
Last Update Date:2018-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0058791041C0700X, 1041C0700X
GACSW0053121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00319017AMedicaid