Provider Demographics
NPI:1447571260
Name:JOHNSON, DOUGLAS EARL SR (MA)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:EARL
Last Name:JOHNSON
Suffix:SR
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 OLD THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:WATHA
Mailing Address - State:NC
Mailing Address - Zip Code:28478-9538
Mailing Address - Country:US
Mailing Address - Phone:910-285-6167
Mailing Address - Fax:
Practice Address - Street 1:334 OLD THOMAS RD
Practice Address - Street 2:
Practice Address - City:WATHA
Practice Address - State:NC
Practice Address - Zip Code:28478-9538
Practice Address - Country:US
Practice Address - Phone:910-285-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-16
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4916101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health