Provider Demographics
NPI:1447070032
Name:JOHNSON, THEODORE C
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8815 TRADEWIND RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-7021
Mailing Address - Country:US
Mailing Address - Phone:505-585-3882
Mailing Address - Fax:505-407-8375
Practice Address - Street 1:525 2ND ST SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3831
Practice Address - Country:US
Practice Address - Phone:505-585-3882
Practice Address - Fax:505-407-8375
Is Sole Proprietor?:No
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor