Provider Demographics
NPI:1386986990
Name:JOHNSON, WILLIAM DERRICK (LPCA, LCASA)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:DERRICK
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LPCA, LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4825 FONTHILL LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-4484
Mailing Address - Country:US
Mailing Address - Phone:704-661-5203
Mailing Address - Fax:
Practice Address - Street 1:1819 CHARLOTTE DR
Practice Address - Street 2:SUITE 200 A
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5775
Practice Address - Country:US
Practice Address - Phone:704-661-5203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-21
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA10034101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health