Provider Demographics
NPI:1629274089
Name:JOHNSON, TISHA M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TISHA
Middle Name:M
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:PO BOX 950032
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30377-2032
Mailing Address - Country:US
Mailing Address - Phone:404-419-7895
Mailing Address - Fax:404-419-7891
Practice Address - Street 1:2255 CUMBERLAND PKWY SE
Practice Address - Street 2:BUILDING 600, SUITE 150
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-4515
Practice Address - Country:US
Practice Address - Phone:404-419-7895
Practice Address - Fax:404-419-7891
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003640103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003135556BMedicaid