Provider Demographics
NPI:1609463801
Name:JOHNSON, MARK LAMONT
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LAMONT
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 1:5626 CRESTHAVEN LN
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1241
Mailing Address - Country:US
Mailing Address - Phone:419-810-4375
Mailing Address - Fax:
Practice Address - Street 1:5626 CRESTHAVEN LN
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-1241
Practice Address - Country:US
Practice Address - Phone:419-810-4375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH8702313103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities