Provider Demographics
NPI:1356340251
Name:JOHNSON, AMY SUE (PSYD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:SUE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:697 PRO-MED LN
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-5323
Mailing Address - Country:US
Mailing Address - Phone:317-587-0567
Mailing Address - Fax:317-574-1230
Practice Address - Street 1:54 N 9TH ST
Practice Address - Street 2:SUITE 205
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-2236
Practice Address - Country:US
Practice Address - Phone:317-587-0567
Practice Address - Fax:317-574-1230
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041576A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN317200HMedicare ID - Type Unspecified