Provider Demographics
NPI:1891393708
Name:JOHNSON, TIMOTHY SR (BACHELOR OF PSYCHOLO)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
Last Name:JOHNSON
Suffix:SR
Gender:M
Credentials:BACHELOR OF PSYCHOLO
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 918
Mailing Address - Street 2:
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512
Mailing Address - Country:US
Mailing Address - Phone:843-544-4060
Mailing Address - Fax:843-454-0635
Practice Address - Street 1:207 PERRY WILEY WAY
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:SC
Practice Address - Zip Code:29709
Practice Address - Country:US
Practice Address - Phone:843-423-8292
Practice Address - Fax:843-423-8294
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC405127Medicaid
SC251S00000XMedicaid