Provider Demographics
NPI:1154873685
Name:JOHNSON, MARLON (LPC, LICDC)
Entity type:Individual
Prefix:
First Name:MARLON
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LPC, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4314 S PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:OH
Mailing Address - Zip Code:44144-2724
Mailing Address - Country:US
Mailing Address - Phone:216-970-8307
Mailing Address - Fax:
Practice Address - Street 1:1744 PAYNE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114-2910
Practice Address - Country:US
Practice Address - Phone:216-623-6555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-01
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.162004101YA0400X
OHE.2202779101YP2500X
OHC.1902406101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0391321Medicaid