Healthcare Provider Details

I. General information

NPI: 1942656244
Provider Name (Legal Business Name): SHIRLEY ANN JOHNSON OHIO LICDC-CSAND LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2016
Last Update Date: 05/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8658 N MAIN ST
DAYTON OH
45415-1328
US

IV. Provider business mailing address

8658 N MAIN ST
DAYTON OH
45415-1328
US

V. Phone/Fax

Practice location:
  • Phone: 937-701-0030
  • Fax: 937-387-9043
Mailing address:
  • Phone: 937-701-0030
  • Fax: 937-387-9043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberLICDC-CS 933508
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberLSW S0021857
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: