Provider Demographics
NPI:1689146078
Name:JOHNSON, GARY L (LMFT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-2255
Mailing Address - Country:US
Mailing Address - Phone:931-247-4764
Mailing Address - Fax:
Practice Address - Street 1:1200 CEDAR LN
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2255
Practice Address - Country:US
Practice Address - Phone:931-247-4764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-22
Last Update Date:2018-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1109106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist