Provider Demographics
NPI:1073016283
Name:JOHNSON, PAUL MARK
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:MARK
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 1:6826 VETERANS BLVD.
Mailing Address - Street 2:311
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70003
Mailing Address - Country:US
Mailing Address - Phone:978-729-3987
Mailing Address - Fax:504-264-7562
Practice Address - Street 1:2955 RIDGELAKE DR STE 105
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-4947
Practice Address - Country:US
Practice Address - Phone:318-728-2970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPLC9110101YP2500X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional