Provider Demographics
NPI:1275977589
Name:JOHNSON, CYNTHIA (PHD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
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:P.O. BOX 1 - FISCAL SERVICES
Mailing Address - Street 2:3550 HIGHWAY, 468 WEST
Mailing Address - City:WHITFIELD
Mailing Address - State:MS
Mailing Address - Zip Code:39193-0157
Mailing Address - Country:US
Mailing Address - Phone:601-351-8000
Mailing Address - Fax:
Practice Address - Street 1:3550 HIGHWAY, 468 WEST
Practice Address - Street 2:FISCAL SERVICES
Practice Address - City:WHITFIELD
Practice Address - State:MS
Practice Address - Zip Code:39193-0157
Practice Address - Country:US
Practice Address - Phone:601-351-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-18
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS35-578103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist