Provider Demographics
NPI:1851645972
Name:JOHNSON, DEANGILA JENALL (CADC-R)
Entity type:Individual
Prefix:
First Name:DEANGILA
Middle Name:JENALL
Last Name:JOHNSON
Suffix:
Gender:
Credentials:CADC-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8570 NORTH CAROLINA 211 E
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-1205
Mailing Address - Country:US
Mailing Address - Phone:910-751-3036
Mailing Address - Fax:
Practice Address - Street 1:8570 NC HIGHWAY 211 E
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-7763
Practice Address - Country:US
Practice Address - Phone:910-751-3036
Practice Address - Fax:910-739-4681
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
NCCADC-30672101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7200535Medicaid