Provider Demographics
NPI:1093012320
Name:JOHNSON, KATRINA ANN (BCBA, LPA)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BCBA, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 MIDDLEBRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-1710
Mailing Address - Country:US
Mailing Address - Phone:704-277-7018
Mailing Address - Fax:
Practice Address - Street 1:1122 SAM NEWELL RD
Practice Address - Street 2:STE 104
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5015
Practice Address - Country:US
Practice Address - Phone:704-277-7018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-23
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NC3685103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst