=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336468271
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDRA D. JOHNSON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2010
-----------------------------------------------------
Last Update Date | 10/17/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4656 W JEFFERSON BLVD SUITE 285
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46804-6857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-422-9372
-----------------------------------------------------
Fax | 260-672-0859
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11014 CONSTANTIA CV
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46783-8910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-798-1997
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. ANDRA D JOHNSON
-----------------------------------------------------
Credential | LISW, LCSW, LCAC
-----------------------------------------------------
Telephone | 216-798-1997
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 991842
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I-0009358
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 2972-123
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 87000438A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 34005636A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------