Provider Demographics
NPI:1083791610
Name:JOHNSON, ROGER L (MA, THM, LPC)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MA, THM, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 N. DALLAS PARKWAY
Mailing Address - Street 2:SUITE 220
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093
Mailing Address - Country:US
Mailing Address - Phone:972-473-0500
Mailing Address - Fax:972-781-0203
Practice Address - Street 1:2800 N. DALLAS PARKWAY
Practice Address - Street 2:SUITE 220
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093
Practice Address - Country:US
Practice Address - Phone:972-473-0500
Practice Address - Fax:972-781-0203
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19785101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional