Provider Demographics
NPI:1518259811
Name:JOHNSON, GARY A (DMIN)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1741 STONEHENGE DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-9113
Mailing Address - Country:US
Mailing Address - Phone:720-545-8193
Mailing Address - Fax:
Practice Address - Street 1:4410 ARAPAHOE AVE STE 205
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1155
Practice Address - Country:US
Practice Address - Phone:720-545-8193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-05
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO796101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional