Provider Demographics
NPI:1083116065
Name:JOHNSON, NICHOLAUS
Entity type:Individual
Prefix:
First Name:NICHOLAUS
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6509 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95820-5842
Mailing Address - Country:US
Mailing Address - Phone:916-274-1727
Mailing Address - Fax:
Practice Address - Street 1:2130 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1337
Practice Address - Country:US
Practice Address - Phone:916-875-0701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1264810917101YA0400X
101YA0400X, 171M00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator