Provider Demographics
NPI:1053828970
Name:JOHNSON, AMY KAY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:KAY
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 1:7107 S YALE AVE # 161
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-6308
Mailing Address - Country:US
Mailing Address - Phone:918-280-0090
Mailing Address - Fax:918-561-6764
Practice Address - Street 1:7107 S YALE AVE # 161
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-6308
Practice Address - Country:US
Practice Address - Phone:918-280-0090
Practice Address - Fax:918-561-6764
Is Sole Proprietor?:No
Enumeration Date:2017-12-30
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1-19-39406103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200882940AMedicaid