Provider Demographics
NPI:1194385708
Name:JOHNSON, EDWARD ROBERT
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:ROBERT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:EDWARD
Other - Middle Name:ROBERT
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RBT
Mailing Address - Street 1:9664 CHANTECLAIR CIR
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80126-3052
Mailing Address - Country:US
Mailing Address - Phone:574-540-9705
Mailing Address - Fax:
Practice Address - Street 1:WEST 6TH AVENUE SUITE 1000
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215-8021
Practice Address - Country:US
Practice Address - Phone:303-233-3122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician