Provider Demographics
NPI:1275973257
Name:JOHNSON, COURTNEY BETH (PHD)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:BETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5995 S COUNTY ROAD 700 E
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-9062
Mailing Address - Country:US
Mailing Address - Phone:317-426-8055
Mailing Address - Fax:
Practice Address - Street 1:2680 E MAIN ST STE 114
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-2827
Practice Address - Country:US
Practice Address - Phone:317-426-8055
Practice Address - Fax:317-900-1900
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-05
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042744A103TC0700X, 103G00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program