Healthcare Provider Details

I. General information

NPI: 1346997848
Provider Name (Legal Business Name): SETH JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2022
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3418 LAKE AVE
ASHTABULA OH
44004-5763
US

IV. Provider business mailing address

3418 LAKE AVE
ASHTABULA OH
44004-5763
US

V. Phone/Fax

Practice location:
  • Phone: 440-650-5030
  • Fax:
Mailing address:
  • Phone: 440-650-5030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number180349
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: