Provider Demographics
NPI:1942770060
Name:JOHNSON, ROBERT TERRY
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:TERRY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:ROBERT
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ROBEARE
Mailing Address - Street 1:6591 REFLECTION DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3119
Mailing Address - Country:US
Mailing Address - Phone:919-264-7208
Mailing Address - Fax:
Practice Address - Street 1:6591 REFLECTION DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92124-3119
Practice Address - Country:US
Practice Address - Phone:919-264-7208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-01
Last Update Date:2018-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician