Provider Demographics
NPI:1386129864
Name:JOHNSON, HALLIE M (BCBA)
Entity type:Individual
Prefix:
First Name:HALLIE
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 SEARLE DR APT 1
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2891
Mailing Address - Country:US
Mailing Address - Phone:130-927-5836
Mailing Address - Fax:
Practice Address - Street 1:2404 E EMPIRE ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3630
Practice Address - Country:US
Practice Address - Phone:309-663-8275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-18-31618103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst