Provider Demographics
NPI:1598440018
Name:JOHNSON, BRYAN
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
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 1:14840 SHEPARD DR
Mailing Address - Street 2:
Mailing Address - City:DOLTON
Mailing Address - State:IL
Mailing Address - Zip Code:60419-2467
Mailing Address - Country:US
Mailing Address - Phone:773-449-0859
Mailing Address - Fax:
Practice Address - Street 1:9115 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-1895
Practice Address - Country:US
Practice Address - Phone:773-449-0859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-21
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician