Provider Demographics
NPI:1619680709
Name:JOHNSON, BENJAMIN ALLEN
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ALLEN
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 1:2840 S CHURCH ST APT B202
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37127-6372
Mailing Address - Country:US
Mailing Address - Phone:208-243-6867
Mailing Address - Fax:
Practice Address - Street 1:538 BRANDIES CIR STE 102
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37128-8423
Practice Address - Country:US
Practice Address - Phone:615-558-5744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician