Provider Demographics
NPI:1609166131
Name:JOHNSON, SHAWN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 RIVERVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3631
Mailing Address - Country:US
Mailing Address - Phone:262-548-7666
Mailing Address - Fax:262-548-7656
Practice Address - Street 1:514 RIVERVIEW AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3631
Practice Address - Country:US
Practice Address - Phone:262-548-7666
Practice Address - Fax:262-548-7656
Is Sole Proprietor?:No
Enumeration Date:2011-04-18
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WI2963-57103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1609166131Medicaid