Provider Demographics
NPI:1306117833
Name:JOHNSON, NATHANIEL (PSYD)
Entity type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 WOODBURY ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-3510
Mailing Address - Country:US
Mailing Address - Phone:617-785-4741
Mailing Address - Fax:
Practice Address - Street 1:260 WASECA AVE
Practice Address - Street 2:
Practice Address - City:BARRINGTON
Practice Address - State:RI
Practice Address - Zip Code:02806-3562
Practice Address - Country:US
Practice Address - Phone:401-245-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01381103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical