Provider Demographics
NPI:1326339276
Name:JOHNSON, JOHN R III (MS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:JOHNSON
Suffix:III
Gender:M
Credentials:MS
Other - Prefix:MR
Other - First Name:JOHN
Other - Middle Name:R
Other - Last Name:JOHNSON
Other - Suffix:III
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:3500 N STATE ROAD 7 STE 211
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5625
Mailing Address - Country:US
Mailing Address - Phone:321-482-0827
Mailing Address - Fax:
Practice Address - Street 1:3500 N STATE ROAD 7 STE 211
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33319-5625
Practice Address - Country:US
Practice Address - Phone:321-604-2742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-27
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional