Provider Demographics
NPI:1033611041
Name:JOHNSON, MARK GLASGOW (MFT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:GLASGOW
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3249 TIMBERWOOD PKWY
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-7232
Mailing Address - Country:US
Mailing Address - Phone:707-303-6712
Mailing Address - Fax:
Practice Address - Street 1:420 3RD ST NE
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-4620
Practice Address - Country:US
Practice Address - Phone:434-886-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717001443106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist