Provider Demographics
NPI:1023876802
Name:JOHNSON, MYRON E (LCPC)
Entity type:Individual
Prefix:
First Name:MYRON
Middle Name:E
Last Name:JOHNSON
Suffix:
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 1:4789 SHAMROCK AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-6864
Mailing Address - Country:US
Mailing Address - Phone:410-446-3292
Mailing Address - Fax:
Practice Address - Street 1:3536 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-6221
Practice Address - Country:US
Practice Address - Phone:443-869-6680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3785101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)