Provider Demographics
NPI:1891532164
Name:JOHNSON, DEDRICK LAMONT JR (MA, RMHCI)
Entity type:Individual
Prefix:
First Name:DEDRICK
Middle Name:LAMONT
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:MA, RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17260 FRANK RD
Mailing Address - Street 2:
Mailing Address - City:ALVA
Mailing Address - State:FL
Mailing Address - Zip Code:33920-3508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12811 KENWOOD LN STE 202
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-5646
Practice Address - Country:US
Practice Address - Phone:239-688-2781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-12
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health