Provider Demographics
NPI:1992896542
Name:JOHNSON, MERLE LEO (LISAC)
Entity type:Individual
Prefix:
First Name:MERLE
Middle Name:LEO
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13376 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:AZ
Mailing Address - Zip Code:85344
Mailing Address - Country:US
Mailing Address - Phone:928-669-5243
Mailing Address - Fax:928-669-5449
Practice Address - Street 1:12033 AGENCY RD
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-7718
Practice Address - Country:US
Practice Address - Phone:928-669-3256
Practice Address - Fax:928-669-5449
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-0884101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ917528OtherAHCCCS