Provider Demographics
NPI:1508515917
Name:JOHNSON, KEVIN MARK
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MARK
Last Name:JOHNSON
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 1:106 CHERRY HILL LN
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7359
Mailing Address - Country:US
Mailing Address - Phone:770-789-8956
Mailing Address - Fax:
Practice Address - Street 1:1170 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3615
Practice Address - Country:US
Practice Address - Phone:404-466-1249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool