Provider Demographics
NPI:1801961214
Name:JOHNSON, MARK C (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:C
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 1:2456 CHRISTIAN STREET
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WHITE RIVER JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05001-1222
Mailing Address - Country:US
Mailing Address - Phone:802-296-3030
Mailing Address - Fax:802-296-8407
Practice Address - Street 1:2456 CHRISTIAN STREET
Practice Address - Street 2:SUITE 204
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05001-1222
Practice Address - Country:US
Practice Address - Phone:802-296-3030
Practice Address - Fax:802-296-8407
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT280103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1002039Medicaid
VTVN3738Medicare ID - Type Unspecified