Provider Demographics
NPI:1245507946
Name:JOHNSON, GWENDOLYN (PHD)
Entity type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MRS
Other - First Name:GWEN
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:3412 MARLA LN
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-8229
Mailing Address - Country:US
Mailing Address - Phone:405-359-8298
Mailing Address - Fax:
Practice Address - Street 1:209 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:OKEMAH
Practice Address - State:OK
Practice Address - Zip Code:74859-2618
Practice Address - Country:US
Practice Address - Phone:918-623-2922
Practice Address - Fax:918-756-2126
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101Y00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKBGJ2011Medicaid