Healthcare Provider Details

I. General information

NPI: 1629577010
Provider Name (Legal Business Name): JOE M JOHNSON III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2018
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 SALEM AVE
DAYTON OH
45406-4941
US

IV. Provider business mailing address

830 N SUMMIT ST
TOLEDO OH
43604-1884
US

V. Phone/Fax

Practice location:
  • Phone: 937-723-8475
  • Fax:
Mailing address:
  • Phone: 419-693-9600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: