Provider Demographics
NPI:1639470636
Name:JOHNSON, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
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 1:3105 NEWCASTLE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75220-1637
Mailing Address - Country:US
Mailing Address - Phone:214-432-6624
Mailing Address - Fax:
Practice Address - Street 1:4314 W LOVERS LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75209-2804
Practice Address - Country:US
Practice Address - Phone:214-432-6624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-06
Last Update Date:2010-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional