Provider Demographics
NPI:1326723404
Name:JOHNSON, AMANDA (PCMHT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PCMHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18679
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-8679
Mailing Address - Country:US
Mailing Address - Phone:601-705-1901
Mailing Address - Fax:
Practice Address - Street 1:1501 LACKEY ST
Practice Address - Street 2:
Practice Address - City:LEAKESVILLE
Practice Address - State:MS
Practice Address - Zip Code:39451-3108
Practice Address - Country:US
Practice Address - Phone:601-394-5047
Practice Address - Fax:601-394-6542
Is Sole Proprietor?:No
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS5930101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor