Provider Demographics
NPI:1962648311
Name:JOHNSON, CHAD VERNON (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:VERNON
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 1:4502 E 41ST ST
Mailing Address - Street 2:SCHUSTERMAN CENTER
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-9923
Mailing Address - Country:US
Mailing Address - Phone:918-406-6763
Mailing Address - Fax:
Practice Address - Street 1:1927 S BOSTON AVE
Practice Address - Street 2:#204
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74119-5259
Practice Address - Country:US
Practice Address - Phone:918-406-6763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1070103TP2701X, 103TC1900X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service