Provider Demographics
NPI:1629215728
Name:JOHNSON, MICHAEL BRUCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRUCE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2406 SUNSET VISTA CIR
Mailing Address - Street 2:
Mailing Address - City:SPICEWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:78669-2094
Mailing Address - Country:US
Mailing Address - Phone:512-228-2126
Mailing Address - Fax:
Practice Address - Street 1:2406 SUNSET VISTA CIR
Practice Address - Street 2:
Practice Address - City:SPICEWOOD
Practice Address - State:TX
Practice Address - Zip Code:78669-2094
Practice Address - Country:US
Practice Address - Phone:512-228-2126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-12
Last Update Date:2022-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003246103TC1900X, 103TE1100X, 103TP2701X
AR13-21P103TC1900X, 103TE1100X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy