Provider Demographics
NPI:1568523561
Name:JOHNSON, LYNN SCOTT (PHD)
Entity Type:Individual
Prefix:MR
First Name:LYNN
Middle Name:SCOTT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 15TH AVE. SOUTH
Mailing Address - Street 2:SUITE #206
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-4334
Mailing Address - Country:US
Mailing Address - Phone:406-454-1696
Mailing Address - Fax:406-454-0496
Practice Address - Street 1:401 15TH AVE. SOUTH
Practice Address - Street 2:SUITE 206
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4334
Practice Address - Country:US
Practice Address - Phone:406-454-1696
Practice Address - Fax:406-454-0496
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT100103TC0700X
MTMTPSCYHOLOGIST#100103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT491478Medicaid
MT05061-1OtherBLUE CROSS-BLUE SHIELD
MTM000005334Medicare PIN
MT491478Medicaid