Provider Demographics
NPI:1336656313
Name:JOHANSEN, JOHNNY THOMAS
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:THOMAS
Last Name:JOHANSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6031 BELL ST.
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109
Mailing Address - Country:US
Mailing Address - Phone:806-367-9358
Mailing Address - Fax:806-500-2772
Practice Address - Street 1:6031 BELL ST.
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109
Practice Address - Country:US
Practice Address - Phone:806-367-9358
Practice Address - Fax:806-500-2772
Is Sole Proprietor?:No
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-16-4937-43967106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician