Basic Information
| Provider Information | |||||||||
| NPI: | 1144456146 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | ADAM | ||||||||
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| Credential: | LSCSW, LMAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 747 | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665050747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855874300 | ||||||||
| FaxNumber: | 7855874377 | ||||||||
| Practice Location | |||||||||
| Address1: | 1558 HAYES DR | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665025068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855874315 | ||||||||
| FaxNumber: | 7855874339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2009 | ||||||||
| LastUpdateDate: | 02/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 008 | KS | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 616 | KS | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | 7407 | KS | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 4234 | KS | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 200609070A | 05 | KS | MEDICAID | 11974774 | 01 | CAQH | OTHER |