Provider Demographics
NPI:1073833638
Name:MICHAEL R JOHNS PSYD
Entity Type:Organization
Organization Name:MICHAEL R JOHNS PSYD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-477-2220
Mailing Address - Street 1:3678 VINEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-1868
Mailing Address - Country:US
Mailing Address - Phone:478-477-2220
Mailing Address - Fax:478-477-4455
Practice Address - Street 1:3678 VINEVILLE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-1868
Practice Address - Country:US
Practice Address - Phone:478-477-2220
Practice Address - Fax:478-477-4455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-07
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002759103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA545766522FMedicaid