Provider Demographics
NPI:1477856714
Name:JOHNSON, ROBERT LEONARD
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:LEONARD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:671 W 150 N
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-5556
Mailing Address - Country:US
Mailing Address - Phone:435-459-9497
Mailing Address - Fax:
Practice Address - Street 1:151 S UNIVERSITY AVE
Practice Address - Street 2:SUITE 3200
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-4427
Practice Address - Country:US
Practice Address - Phone:801-851-7129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator