Provider Demographics
NPI:1083335962
Name:JOHNSON, GWENDOLYN (BCBA)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:985 BRUTON CT SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-2971
Mailing Address - Country:US
Mailing Address - Phone:404-488-7811
Mailing Address - Fax:
Practice Address - Street 1:968 ANISE LN
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-7775
Practice Address - Country:US
Practice Address - Phone:404-488-7811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-08
Last Update Date:2024-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-24-70492103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician