Provider Demographics
NPI:1063144889
Name:JOHNSON, COREY (LADC)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8031 W CENTER RD STE 305
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-3134
Mailing Address - Country:US
Mailing Address - Phone:402-235-8341
Mailing Address - Fax:
Practice Address - Street 1:8031 WEST CENTER RD
Practice Address - Street 2:SUITE 305
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124
Practice Address - Country:US
Practice Address - Phone:402-235-8341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-29
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1580101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty