Provider Demographics
NPI:1609946375
Name:JOHNSON, ROBERT B (EDD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3434 BROOK VIEW LN
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-1592
Mailing Address - Country:US
Mailing Address - Phone:801-949-9554
Mailing Address - Fax:
Practice Address - Street 1:1800 S WEST TEMPLE # A110
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-1851
Practice Address - Country:US
Practice Address - Phone:801-949-9554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1072762501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist