Provider Demographics
NPI:1710999735
Name:JOHNSON, SAMUEL GARY I (MA, LPC)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:GARY
Last Name:JOHNSON
Suffix:I
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 CENTRAL AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:OIL CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16301-2733
Mailing Address - Country:US
Mailing Address - Phone:814-678-6900
Mailing Address - Fax:814-678-6902
Practice Address - Street 1:19 CENTRAL AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:OIL CITY
Practice Address - State:PA
Practice Address - Zip Code:16301-2733
Practice Address - Country:US
Practice Address - Phone:814-678-6900
Practice Address - Fax:814-678-6902
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC003785101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA372735OtherMHN
PA1748907OtherBLUE SHIELD
PA565603OtherVALUE OPTIONS