Provider Demographics
NPI:1689644700
Name:NIEDERJOHN, DANIEL MARK (PHD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:MARK
Last Name:NIEDERJOHN
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 1:784 MITSY PT
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-2332
Mailing Address - Country:US
Mailing Address - Phone:678-778-2260
Mailing Address - Fax:
Practice Address - Street 1:8910 MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-4916
Practice Address - Country:US
Practice Address - Phone:678-778-2260
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002826103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical