Healthcare Provider Details

I. General information

NPI: 1689534612
Provider Name (Legal Business Name): TAIYA JOHNSON LVN, CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2025
Last Update Date: 11/19/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7058 CORPORATE WAY STE 3
DAYTON OH
45459-4243
US

IV. Provider business mailing address

1702 RIVER TRL
SUGAR LAND TX
77479-6339
US

V. Phone/Fax

Practice location:
  • Phone: 937-991-0080
  • Fax:
Mailing address:
  • Phone: 313-971-2188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number1180698
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA194265
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: