Provider Demographics
NPI:1225078066
Name:JOHNSON, CHARLES (PHD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-4004
Mailing Address - Country:US
Mailing Address - Phone:215-925-2400
Mailing Address - Fax:
Practice Address - Street 1:1401 S 4TH ST
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19147-5907
Practice Address - Country:US
Practice Address - Phone:215-339-1079
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS003915103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA726135Medicare ID - Type Unspecified
PAS34686Medicare UPIN