Provider Demographics
NPI:1073962601
Name:JOHNSON, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
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 1:650 E 4500 S
Mailing Address - Street 2:#300
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2900
Mailing Address - Country:US
Mailing Address - Phone:801-261-3500
Mailing Address - Fax:801-261-3500
Practice Address - Street 1:650 E 4500 S
Practice Address - Street 2:#300
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2900
Practice Address - Country:US
Practice Address - Phone:801-261-3500
Practice Address - Fax:801-261-3500
Is Sole Proprietor?:No
Enumeration Date:2016-06-04
Last Update Date:2016-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health