Provider Demographics
NPI:1912972167
Name:JOHNSON, CRAIG L (PHD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:L
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:PO BOX 21228
Mailing Address - Street 2:DEPARTMENT 31
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74121-1228
Mailing Address - Country:US
Mailing Address - Phone:918-491-3702
Mailing Address - Fax:918-491-5740
Practice Address - Street 1:6655 S YALE AVE
Practice Address - Street 2:LAUREATE PSYCHIATRIC CLINIC AND HOSPITAL
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3326
Practice Address - Country:US
Practice Address - Phone:918-491-3702
Practice Address - Fax:918-491-5740
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK563103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
2136705OtherCIGNA BEHAVIORAL HEALTH
2136705OtherCIGNA BEHAVIORAL HEALTH