Provider Demographics
NPI:1235796004
Name:JOHNSON, BRIAN BURKE (PLMHP)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:BURKE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2313 N WEBB RD
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-1743
Mailing Address - Country:US
Mailing Address - Phone:308-381-8851
Mailing Address - Fax:308-381-8853
Practice Address - Street 1:13460 WALSH DR
Practice Address - Street 2:
Practice Address - City:BOYS TOWN
Practice Address - State:NE
Practice Address - Zip Code:68010-7529
Practice Address - Country:US
Practice Address - Phone:531-355-3358
Practice Address - Fax:531-355-3375
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11864101Y00000X
GAPSY004540103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor