Healthcare Provider Details

I. General information

NPI: 1780022111
Provider Name (Legal Business Name): MR. CARDELL JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2013
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2744 E 28TH ST N
TULSA OK
74110-1823
US

IV. Provider business mailing address

7010 S YALE AVE
TULSA OK
74136-5713
US

V. Phone/Fax

Practice location:
  • Phone: 918-902-3543
  • Fax:
Mailing address:
  • Phone: 918-492-2554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: