Provider Demographics
NPI:1760580583
Name:JOHNSON, JOEL I (PHD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:I
Last Name:JOHNSON
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:PO BOX 770211
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38177-0211
Mailing Address - Country:US
Mailing Address - Phone:901-216-4354
Mailing Address - Fax:
Practice Address - Street 1:6244 POPLAR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4732
Practice Address - Country:US
Practice Address - Phone:901-216-4354
Practice Address - Fax:888-519-3386
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP1022103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2004638OtherTN BC/BS PROV#
TN3982789Medicare ID - Type UnspecifiedTN MEDICARE PROV #
B02654Medicare UPIN