Provider Demographics
NPI:1104081934
Name:JOHNSON, REBECCA MARY (PSYD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:MARY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 JOHN WESLEY DOBBS AVE NE
Mailing Address - Street 2:SUITE 180
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-5324
Mailing Address - Country:US
Mailing Address - Phone:404-919-5137
Mailing Address - Fax:
Practice Address - Street 1:480 JOHN WESLEY DOBBS AVE NE
Practice Address - Street 2:SUITE 180
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-5324
Practice Address - Country:US
Practice Address - Phone:404-919-5137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-21
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
GAPSY003736103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health