Provider Demographics
NPI:1982363453
Name:JOHNSON, GRYPHON L
Entity Type:Individual
Prefix:
First Name:GRYPHON
Middle Name:L
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 1:535 MARMION AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44502-2323
Mailing Address - Country:US
Mailing Address - Phone:330-782-5664
Mailing Address - Fax:330-782-1614
Practice Address - Street 1:535 MARMION AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44502-2323
Practice Address - Country:US
Practice Address - Phone:330-782-5664
Practice Address - Fax:330-782-1614
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-13
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2103639-TRNE101Y00000X
OHC.2304857101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor