Provider Demographics
NPI:1710513288
Name:JOHNSON, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
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 1:1330 QUAIL LAKE LOOP STE 200
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-4651
Mailing Address - Country:US
Mailing Address - Phone:719-540-2108
Mailing Address - Fax:
Practice Address - Street 1:1330 QUAIL LAKE LOOP STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4651
Practice Address - Country:US
Practice Address - Phone:719-540-2108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0-22-13463106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst