Provider Demographics
NPI:1710736459
Name:JOHNSON, DEVAN WW (LAC)
Entity type:Individual
Prefix:
First Name:DEVAN
Middle Name:WW
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 EMERALD RIDGE RD APT 111
Mailing Address - Street 2:
Mailing Address - City:WATFORD CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58854-8512
Mailing Address - Country:US
Mailing Address - Phone:701-500-2194
Mailing Address - Fax:
Practice Address - Street 1:2126 VISTA AVE, ARNEGARD, ND 58835
Practice Address - Street 2:
Practice Address - City:ARNEGARD
Practice Address - State:ND
Practice Address - Zip Code:58835
Practice Address - Country:US
Practice Address - Phone:701-586-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1976101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)