Provider Demographics
NPI:1982247839
Name:JOHNSON, DONALD CLARK (LADC-I)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:CLARK
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LADC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 LOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:HOLDEN
Mailing Address - State:MA
Mailing Address - Zip Code:01520-2134
Mailing Address - Country:US
Mailing Address - Phone:774-364-4569
Mailing Address - Fax:
Practice Address - Street 1:16 LOWELL AVE
Practice Address - Street 2:
Practice Address - City:HOLDEN
Practice Address - State:MA
Practice Address - Zip Code:01520-2134
Practice Address - Country:US
Practice Address - Phone:774-364-4569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18560101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)