Provider Demographics
NPI:1700599867
Name:JOHNSON, CLARENCE ANTHONY III
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:ANTHONY
Last Name:JOHNSON
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6145 IMPERIAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114-4213
Mailing Address - Country:US
Mailing Address - Phone:619-234-8888
Mailing Address - Fax:
Practice Address - Street 1:6145 IMPERIAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92114-4213
Practice Address - Country:US
Practice Address - Phone:619-234-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-03
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33-0539640Medicaid