Provider Demographics
NPI:1891709432
Name:JOHNSON, LYNN DOUGLAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:LYNN
Middle Name:DOUGLAS
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 1:166 E 5900 S
Mailing Address - Street 2:STE B-108
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7257
Mailing Address - Country:US
Mailing Address - Phone:801-261-1412
Mailing Address - Fax:801-288-2269
Practice Address - Street 1:166 E 5900 S
Practice Address - Street 2:STE B-108
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-7257
Practice Address - Country:US
Practice Address - Phone:801-261-1412
Practice Address - Fax:801-288-2269
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT108316-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist