Provider Demographics
NPI:1184209298
Name:JOHNSON, AMANDA REANE (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:REANE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 S 96TH PL
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85208-2512
Mailing Address - Country:US
Mailing Address - Phone:623-272-5449
Mailing Address - Fax:
Practice Address - Street 1:544 S 96TH PL
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85208-2512
Practice Address - Country:US
Practice Address - Phone:480-696-0338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC1063923340103K00000X
AZ1063923340103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1003008277Medicaid
1063923340OtherBEHAVIORAL ANALYSIS
AZ103K00000XMedicaid