Provider Demographics
NPI:1932534260
Name:JOHNSON, MATTHEW TRUMAN
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:TRUMAN
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 1:480 E 100 S
Mailing Address - Street 2:
Mailing Address - City:EPHRAIM
Mailing Address - State:UT
Mailing Address - Zip Code:84627-5550
Mailing Address - Country:US
Mailing Address - Phone:435-899-1624
Mailing Address - Fax:
Practice Address - Street 1:2860 E 19500 N
Practice Address - Street 2:
Practice Address - City:MORONI
Practice Address - State:UT
Practice Address - Zip Code:84646
Practice Address - Country:US
Practice Address - Phone:435-436-9029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1235458555Medicaid