Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 14554 | TX |
NPI | 1003411182 |
---|---|
Provider Name | Colleen Casey Johnson |
First Address | Fort Worth, TX 76107-7277 |
Second Address | Fort Worth, TX 76107-7277 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/12/2020 |
Last Update Date | 04/12/2020 |