Provider Demographics
NPI:1770450892
Name:JOHNSON, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
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 1:6215 GREENBELT RD STE 107
Mailing Address - Street 2:
Mailing Address - City:BERWYN HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20740-2355
Mailing Address - Country:US
Mailing Address - Phone:301-272-1558
Mailing Address - Fax:
Practice Address - Street 1:6215 GREENBELT RD STE 107
Practice Address - Street 2:
Practice Address - City:BERWYN HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20740-2355
Practice Address - Country:US
Practice Address - Phone:301-272-1558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-22
Last Update Date:2025-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR259140363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health