Provider Demographics
NPI:1225184021
Name:JOHNSON, MICHAEL PHILLIP (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PHILLIP
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 1:2432 CASCADE TRL
Mailing Address - Street 2:
Mailing Address - City:COOL
Mailing Address - State:CA
Mailing Address - Zip Code:95614-2603
Mailing Address - Country:US
Mailing Address - Phone:530-887-1846
Mailing Address - Fax:
Practice Address - Street 1:11670 ATWOOD RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-9522
Practice Address - Country:US
Practice Address - Phone:530-887-2828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS742101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health