Provider Demographics
NPI:1760491997
Name:JOHNSON, MARIE ELIZABETH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:ELIZABETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22W245 HACKBERRY DR
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-7348
Mailing Address - Country:US
Mailing Address - Phone:630-469-0162
Mailing Address - Fax:630-469-0536
Practice Address - Street 1:1010 JORIE BOULEVARD
Practice Address - Street 2:SUITE 246
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1234
Practice Address - Country:US
Practice Address - Phone:630-415-3455
Practice Address - Fax:630-469-0536
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-006872103TC0700X
IN20041999A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical