Provider Demographics
NPI:1285251397
Name:JOHNSON, ELMER EUGENE
Entity type:Individual
Prefix:
First Name:ELMER
Middle Name:EUGENE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 CITYVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7017
Mailing Address - Country:US
Mailing Address - Phone:970-261-8244
Mailing Address - Fax:
Practice Address - Street 1:184 CITYVIEW AVE
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7017
Practice Address - Country:US
Practice Address - Phone:970-261-8244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)