Provider Demographics
NPI:1861114944
Name:JOHNSON, ANTWINE DEON SR (LCADC)
Entity type:Individual
Prefix:
First Name:ANTWINE
Middle Name:DEON
Last Name:JOHNSON
Suffix:SR
Gender:M
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 CUTHBERT BLVD
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002-3417
Mailing Address - Country:US
Mailing Address - Phone:856-890-9449
Mailing Address - Fax:
Practice Address - Street 1:2131 46TH ST
Practice Address - Street 2:
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08110-2011
Practice Address - Country:US
Practice Address - Phone:609-707-3444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00332600101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)