Provider Demographics
NPI:1003893900
Name:JOHNSON, FREDERICK VINCENT (PSYD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:VINCENT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARVER
Mailing Address - State:MA
Mailing Address - Zip Code:02330-1128
Mailing Address - Country:US
Mailing Address - Phone:508-866-5000
Mailing Address - Fax:
Practice Address - Street 1:68 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CARVER
Practice Address - State:MA
Practice Address - Zip Code:02330-1128
Practice Address - Country:US
Practice Address - Phone:508-866-5000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6678103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA859839OtherMA. LIC. HEALTH CARE PROV
MA859839OtherMA. LIC. HEALTH CARE PROV