Provider Demographics
NPI:1952774812
Name:JOHNSON, ARCHIE (PHD)
Entity type:Individual
Prefix:DR
First Name:ARCHIE
Middle Name:
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 1:1107 48TH AVE N, PKWY OFC PLAZA, SUIT 310 D
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5443
Mailing Address - Country:US
Mailing Address - Phone:843-459-8154
Mailing Address - Fax:843-347-9596
Practice Address - Street 1:1107 48TH AVE N
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5443
Practice Address - Country:US
Practice Address - Phone:843-459-8154
Practice Address - Fax:843-347-9596
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-01
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2790102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst