Provider Demographics
NPI:1841662749
Name:JOHNSON, ERNEST III
Entity type:Individual
Prefix:
First Name:ERNEST
Middle Name:
Last Name:JOHNSON
Suffix:III
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 1:1300 S EBRIGHT ST
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47302-3542
Mailing Address - Country:US
Mailing Address - Phone:765-215-0205
Mailing Address - Fax:
Practice Address - Street 1:1300 S EBRIGHT ST
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47302-3542
Practice Address - Country:US
Practice Address - Phone:765-215-0205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-30
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst