Provider Demographics
NPI:1013141811
Name:JOHNSON, MATTHEW CHRISTIAN (PHD)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:CHRISTIAN
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 1:3010 MITCHELLVILLE ROAD
Mailing Address - Street 2:SUITE #104
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716
Mailing Address - Country:US
Mailing Address - Phone:301-390-2742
Mailing Address - Fax:
Practice Address - Street 1:3010 MITCHELLVILLE ROAD
Practice Address - Street 2:SUITE #104
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716
Practice Address - Country:US
Practice Address - Phone:301-390-2742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-07
Last Update Date:2017-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05910103T00000X
PA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist