Provider Demographics
NPI:1265511539
Name:JOHNSON, THOMAS B (EDD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 GOFF ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-5019
Mailing Address - Country:US
Mailing Address - Phone:207-784-5795
Mailing Address - Fax:207-784-5796
Practice Address - Street 1:2 GOFF ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-5019
Practice Address - Country:US
Practice Address - Phone:207-784-5795
Practice Address - Fax:207-784-5796
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS177103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist