Healthcare Provider Details

I. General information

NPI: 1255830667
Provider Name (Legal Business Name): ANITRA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2018
Last Update Date: 07/21/2022
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6605 W CENTRAL AVE
TOLEDO OH
43617-1000
US

IV. Provider business mailing address

2005 ASHLAND AVE
TOLEDO OH
43620-1703
US

V. Phone/Fax

Practice location:
  • Phone: 419-841-7701
  • Fax:
Mailing address:
  • Phone: 419-841-7701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: