Provider Demographics
NPI:1841912003
Name:JOHNSON, PAETYN
Entity type:Individual
Prefix:
First Name:PAETYN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5751 KROGER DR STE 141
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-5633
Mailing Address - Country:US
Mailing Address - Phone:940-441-3550
Mailing Address - Fax:
Practice Address - Street 1:5751 KROGER DR STE 141
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-5633
Practice Address - Country:US
Practice Address - Phone:940-441-3550
Practice Address - Fax:940-448-3200
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7313106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst