Provider Demographics
NPI:1689919086
Name:JOHNSON, DANIEL LOGAN
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:LOGAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 BAINBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-2135
Mailing Address - Country:US
Mailing Address - Phone:540-604-0071
Mailing Address - Fax:
Practice Address - Street 1:4100 PRICE CLUB BLVD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3379
Practice Address - Country:US
Practice Address - Phone:804-674-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst