Healthcare Provider Details

I. General information

NPI: 1588640700
Provider Name (Legal Business Name): MICHAEL ANTHONY JOHNSON MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 01/09/2025
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 MALLARD CT
BECKLEY WV
25801-3664
US

IV. Provider business mailing address

252 RURAL ACRES DR
BECKLEY WV
25801-3503
US

V. Phone/Fax

Practice location:
  • Phone: 304-252-8409
  • Fax: 304-252-0022
Mailing address:
  • Phone: 304-252-8409
  • Fax: 304-252-0022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberDP00939097
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: