Provider Demographics
NPI:1861049900
Name:JOHNSON, ADAM EDWARD (MA, LPC, NCC)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:EDWARD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1132
Mailing Address - Street 2:
Mailing Address - City:BERTHOUD
Mailing Address - State:CO
Mailing Address - Zip Code:80513-2132
Mailing Address - Country:US
Mailing Address - Phone:847-819-2458
Mailing Address - Fax:
Practice Address - Street 1:515 MOUNT RAINIER ST
Practice Address - Street 2:
Practice Address - City:BERTHOUD
Practice Address - State:CO
Practice Address - Zip Code:80513-1482
Practice Address - Country:US
Practice Address - Phone:847-819-2458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0011855101YP2500X, 101YM0800X, 101YP1600X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000183633Medicaid