Healthcare Provider Details

I. General information

NPI: 1114563764
Provider Name (Legal Business Name): CYNTHIA ANN JOHNSON MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 PONDELLA RD STE 9
NORTH FORT MYERS FL
33903-4340
US

IV. Provider business mailing address

3105 40TH ST SW
LEHIGH ACRES FL
33976-4602
US

V. Phone/Fax

Practice location:
  • Phone: 239-652-0260
  • Fax: 239-652-0146
Mailing address:
  • Phone: 301-659-4060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCWCMP102942
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: