Provider Demographics
NPI:1174661003
Name:DAN JOHNSON PHD CLINICAL NEUROPSYCHOLOGIST,P.A.
Entity Type:Organization
Organization Name:DAN JOHNSON PHD CLINICAL NEUROPSYCHOLOGIST,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:870-933-5174
Mailing Address - Street 1:1201 FLEMING AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4311
Mailing Address - Country:US
Mailing Address - Phone:870-933-5174
Mailing Address - Fax:870-933-5235
Practice Address - Street 1:1201 FLEMING AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4311
Practice Address - Country:US
Practice Address - Phone:870-933-5174
Practice Address - Fax:870-933-5235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR01-10P174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F374Medicare ID - Type UnspecifiedGROUP