Provider Demographics
NPI:1649555392
Name:JOHNSON, TIMOTHY BOGART
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:BOGART
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 1:3785 E SUNSET RD STE 10
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-6260
Mailing Address - Country:US
Mailing Address - Phone:702-985-2345
Mailing Address - Fax:
Practice Address - Street 1:3785 E SUNSET RD STE 10
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-6260
Practice Address - Country:US
Practice Address - Phone:702-985-2345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional