Provider Demographics
NPI:1366564890
Name:JOHNSON, CAROL ADRIENNE
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:ADRIENNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:ADRIENNE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CEO/QP
Mailing Address - Street 1:2509 ROLLING PINES AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-5933
Mailing Address - Country:US
Mailing Address - Phone:919-598-6416
Mailing Address - Fax:
Practice Address - Street 1:2509 ROLLING PINES AVE
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-5933
Practice Address - Country:US
Practice Address - Phone:919-598-6416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC032317320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities