Provider Demographics
NPI:1932100518
Name:JOHNSON, MARK H (PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:H
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 1:400 15TH AVE S STE 205
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-4375
Mailing Address - Country:US
Mailing Address - Phone:406-731-8888
Mailing Address - Fax:406-731-8876
Practice Address - Street 1:400 15TH AVE S STE 205
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4375
Practice Address - Country:US
Practice Address - Phone:406-731-8888
Practice Address - Fax:406-731-8876
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT198103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000005501Medicare ID - Type Unspecified