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General NPI Number Information
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NPI Number | 1093787426
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Entity Type | Individual
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Provider Name | ANDRA D. JOHNSON LISW, LCSW, LCAC
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Gender | Female
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Dates
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Enumeration Date | 02/01/2006
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Last Update Date | 10/17/2011
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Provider Practice Location Address
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Address Line | 4656 W JEFFERSON BLVD SUITE 285
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City | FORT WAYNE
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State | IN
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Zip | 46804-6857
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Country | US
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Telephone | 260-422-9372
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Fax | 260-672-0859
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Provider Business Mailing Address
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Address Line | 11014 CONSTANTIA CV
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City | ROANOKE
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State | IN
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Zip | 46783-8910
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Country | US
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Telephone | 216-798-1997
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Fax | 260-672-0859
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 991842 (LICDC)
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | I - 0009358 (LISW)
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License Number State | OH
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 2979-123 (LCSW)
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License Number State | WI
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 34005636A (LCSW)
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License Number State | IN
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Taxonomy #5
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 87000438A (LCAC)
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License Number State | IN
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