Provider Demographics
NPI:1649895749
Name:JOHNSON, MALIK DEVON
Entity type:Individual
Prefix:
First Name:MALIK
Middle Name:DEVON
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 1:3317 MCELDERRY ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21205-2820
Mailing Address - Country:US
Mailing Address - Phone:443-597-6027
Mailing Address - Fax:
Practice Address - Street 1:4317 HARFORD RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21214-3118
Practice Address - Country:US
Practice Address - Phone:443-708-5310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-15
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC11606101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD38-3876389Medicaid