Healthcare Provider Details

I. General information

NPI: 1780135780
Provider Name (Legal Business Name): DORETTE L JOHNSON CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 09/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 SPRING AVE NE
CANTON OH
44714-2349
US

IV. Provider business mailing address

625 CLEVELAND AVE NW
CANTON OH
44702-1805
US

V. Phone/Fax

Practice location:
  • Phone: 330-454-6800
  • Fax: 330-588-7176
Mailing address:
  • Phone: 330-453-8252
  • Fax: 330-453-6716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.150089
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: