Provider Demographics
NPI:1407292089
Name:JOHNSON, LAURIE JEANNINE (LCDCIII)
Entity type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:JEANNINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 N VANDEMARK RD
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-3567
Mailing Address - Country:US
Mailing Address - Phone:937-492-8080
Mailing Address - Fax:937-492-6971
Practice Address - Street 1:1101 N VANDEMARK RD
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-3567
Practice Address - Country:US
Practice Address - Phone:937-492-8080
Practice Address - Fax:937-492-6971
Is Sole Proprietor?:No
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH081008101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)