Provider Demographics
NPI:1861694051
Name:JOHNSON, DALTON JAMES JR (LCPC)
Entity type:Individual
Prefix:MR
First Name:DALTON
Middle Name:JAMES
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 PRESTANCIA PL APT 107
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-4119
Mailing Address - Country:US
Mailing Address - Phone:301-645-5460
Mailing Address - Fax:
Practice Address - Street 1:4660 PRESTANCIA PL APT 107
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-4119
Practice Address - Country:US
Practice Address - Phone:301-645-5460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
MDLCO791101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD303902100Medicaid