Provider Demographics
NPI:1649345208
Name:JOHNSON, MATTHEW DAVID (PHD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BU DEPARTMENT OF PSYCHOLOGY
Mailing Address - Street 2:BOX 6000
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13902-6000
Mailing Address - Country:US
Mailing Address - Phone:607-777-6315
Mailing Address - Fax:607-777-4733
Practice Address - Street 1:4400 VESTAL PARKWAY EAST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13902-6000
Practice Address - Country:US
Practice Address - Phone:607-777-2103
Practice Address - Fax:607-777-4733
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014850103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000135453OtherBLUE CROSS BLUE SHIELD OF
NY418400OtherMVP INSURANCE
NY418400OtherMVP INSURANCE