Provider Demographics
NPI:1477759405
Name:JOHNSON, DEBORAH HAZEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:HAZEL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13709 CASTLE CLIFF WAY
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-5473
Mailing Address - Country:US
Mailing Address - Phone:301-384-3661
Mailing Address - Fax:301-384-7415
Practice Address - Street 1:10715 CHARTER DR STE 270
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2871
Practice Address - Country:US
Practice Address - Phone:410-997-8191
Practice Address - Fax:301-384-7415
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1285103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD492287OtherMEDICARE PTAN
MD492287Medicare PIN
MDG383Medicare PIN
MDR10546Medicare ID - Type Unspecified