Provider Demographics
NPI:1760206775
Name:DANTZLER-JOHNSON, NIKO (LPC)
Entity type:Individual
Prefix:
First Name:NIKO
Middle Name:
Last Name:DANTZLER-JOHNSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 E UPSAL ST APT 106
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-3937
Mailing Address - Country:US
Mailing Address - Phone:215-490-6404
Mailing Address - Fax:
Practice Address - Street 1:615 E UPSAL ST APT 106
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-3937
Practice Address - Country:US
Practice Address - Phone:215-395-5238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-15
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC017685101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health