Provider Demographics
NPI:1881377281
Name:JOHNSON, CLARISSA CHAVON
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:CHAVON
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1958 MAPLE AVE # 2
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2028
Mailing Address - Country:US
Mailing Address - Phone:513-413-0491
Mailing Address - Fax:
Practice Address - Street 1:1958 MAPLE AVE # 2
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45212-2028
Practice Address - Country:US
Practice Address - Phone:513-413-0491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-11
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services