Healthcare Provider Details

I. General information

NPI: 1982844973
Provider Name (Legal Business Name): CYNTHIA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 03/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10625 S MICHIGAN AVE
CHICAGO IL
60628-2707
US

IV. Provider business mailing address

10625 S MICHIGAN AVE
CHICAGO IL
60628-2707
US

V. Phone/Fax

Practice location:
  • Phone: 773-928-1109
  • Fax: 773-928-2099
Mailing address:
  • Phone: 773-928-1109
  • Fax: 773-928-2099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberJ52510455820
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: