Provider Demographics
NPI:1194977298
Name:JOHNSON, BENETTA E (PHD, HSPP)
Entity type:Individual
Prefix:DR
First Name:BENETTA
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5610 CRAWFORDSVILLE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46224-3714
Mailing Address - Country:US
Mailing Address - Phone:317-241-4673
Mailing Address - Fax:317-241-0201
Practice Address - Street 1:5610 CRAWFORDSVILLE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-3714
Practice Address - Country:US
Practice Address - Phone:317-241-4673
Practice Address - Fax:317-241-0201
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99034346A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty