Provider Demographics
NPI:1306594577
Name:JOHNSON, MARILYN GRACE (LBS)
Entity type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:GRACE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 RENAISSANCE DR STE 401
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:PA
Mailing Address - Zip Code:16001-7612
Mailing Address - Country:US
Mailing Address - Phone:724-421-3655
Mailing Address - Fax:
Practice Address - Street 1:200 RENAISSANCE DR STE 401
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:PA
Practice Address - Zip Code:16001-7612
Practice Address - Country:US
Practice Address - Phone:724-421-3655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH000450103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst