Provider Demographics
NPI:1124508270
Name:JOHNSON, KYLE (PHD, NCSP)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 WATCH HOUSE CIR S
Mailing Address - Street 2:
Mailing Address - City:SEVERN
Mailing Address - State:MD
Mailing Address - Zip Code:21144-5015
Mailing Address - Country:US
Mailing Address - Phone:205-999-1726
Mailing Address - Fax:
Practice Address - Street 1:11307 SUNSET HILLS RD STE B4
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5279
Practice Address - Country:US
Practice Address - Phone:410-914-7795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005813103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical