Provider Demographics
NPI:1831280775
Name:JOHNSON, GARY M (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:M
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 1:2311 W 17TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806-1330
Mailing Address - Country:US
Mailing Address - Phone:302-521-7995
Mailing Address - Fax:302-351-8706
Practice Address - Street 1:2311 W 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806-1330
Practice Address - Country:US
Practice Address - Phone:302-521-7995
Practice Address - Fax:302-351-8706
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB-10000132103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE072298Medicare ID - Type Unspecified