Provider Demographics
NPI:1417249178
Name:JOHNSON, AUDREA YOUNGMAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:AUDREA
Middle Name:YOUNGMAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:AUDREA
Other - Middle Name:REA
Other - Last Name:YOUNGMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:3613 WILLIAMS DR STE 1005
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-1376
Mailing Address - Country:US
Mailing Address - Phone:737-279-4700
Mailing Address - Fax:737-279-4500
Practice Address - Street 1:3613 WILLIAMS DR STE 1005
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-1376
Practice Address - Country:US
Practice Address - Phone:737-279-4700
Practice Address - Fax:737-279-4500
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool