Provider Demographics
NPI:1306877527
Name:JOHNSON, RICHARD EARL (PHD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:EARL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 6TH AVE STE B
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-3800
Mailing Address - Country:US
Mailing Address - Phone:817-846-8466
Mailing Address - Fax:817-288-0958
Practice Address - Street 1:3109 6TH AVE
Practice Address - Street 2:STE B
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-3800
Practice Address - Country:US
Practice Address - Phone:817-846-8466
Practice Address - Fax:817-288-0958
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25795103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1008109OtherAMERIGROUP
TX0077THOtherBCBS PROVIDER ID
TX102647805Medicaid
TX8B8909OtherBCBS
TX102647804Medicaid
TX8B8909Medicare ID - Type Unspecified
TX610065Medicare PIN
TX0077THOtherBCBS PROVIDER ID