Provider Demographics
NPI:1073902466
Name:JOHNSON, MARK J (PSYD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
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 1:409 S 2ND ST
Mailing Address - Street 2:SUITE 2F
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:717-231-8360
Mailing Address - Fax:717-231-8358
Practice Address - Street 1:205 S FRONT ST
Practice Address - Street 2:5TH FLOOR BMA
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17104-1619
Practice Address - Country:US
Practice Address - Phone:717-231-8360
Practice Address - Fax:717-231-8358
Is Sole Proprietor?:No
Enumeration Date:2015-01-22
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015349103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103002852Medicaid
PA103002852Medicaid