Provider Demographics
NPI:1639763733
Name:JOHNSON, AMANDA LYNN (MS)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LYNN
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:3565 PIEDMONT ROAD NE
Mailing Address - Street 2:BUILDING TWO, SUITE 510
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305
Mailing Address - Country:US
Mailing Address - Phone:404-618-0601
Mailing Address - Fax:
Practice Address - Street 1:3565 PIEDMONT ROAD NE
Practice Address - Street 2:BUILDING TWO, SUITE 510
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-3030
Practice Address - Country:US
Practice Address - Phone:404-618-0601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000525106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist