Provider Demographics
NPI:1992235576
Name:JOHNSON, EDITH H (LPAT)
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:H
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40203-2202
Mailing Address - Country:US
Mailing Address - Phone:502-585-9444
Mailing Address - Fax:502-585-9466
Practice Address - Street 1:900 W SOUTH BOUNDARY ST BLDG 6
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-5235
Practice Address - Country:US
Practice Address - Phone:614-339-0806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-15
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY173535101YM0800X
KY262144221700000X
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid