Provider Demographics
NPI:1902445372
Name:JOHNSON, AVIDA ASHLEY-EVELYN (LLMSW)
Entity Type:Individual
Prefix:
First Name:AVIDA
Middle Name:ASHLEY-EVELYN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 N WASHINGTON ST OFC 14C
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-2662
Mailing Address - Country:US
Mailing Address - Phone:419-746-5579
Mailing Address - Fax:
Practice Address - Street 1:32 N WASHINGTON ST OFC 14C
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-2662
Practice Address - Country:US
Practice Address - Phone:419-746-5579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-02
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health