Provider Demographics
NPI:1356446777
Name:JOHNSON, THEODORE MARTIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:MARTIN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 LILLY RD NE
Mailing Address - Street 2:#205
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5195
Mailing Address - Country:US
Mailing Address - Phone:360-413-8222
Mailing Address - Fax:360-413-8205
Practice Address - Street 1:500 LILLY RD NE
Practice Address - Street 2:#205
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5195
Practice Address - Country:US
Practice Address - Phone:360-413-8222
Practice Address - Fax:360-413-8205
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY2977103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8806325Medicare ID - Type Unspecified