Healthcare Provider Details

I. General information

NPI: 1790745404
Provider Name (Legal Business Name): RANDY J. JOHNSON LCMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2006
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2235 LEWISVILLE CLEMMONS RD STE A
CLEMMONS NC
27012-9342
US

IV. Provider business mailing address

713 S MARSHALL ST
WINSTON SALEM NC
27101-5808
US

V. Phone/Fax

Practice location:
  • Phone: 336-722-7266
  • Fax: 336-201-0538
Mailing address:
  • Phone: 336-722-7266
  • Fax: 336-201-0538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3008
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier6102482
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 2
Identifier1236V
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBCBS OF NC
# 3
IdentifierD9674
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerMEDCOST
# 4
Identifier6102747
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 5
IdentifierD0751
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerMEDCOST

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: