Provider Demographics
NPI:1386904688
Name:JOHNSON, MARK L (PHD)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:L
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 1:15047 LOS GATOS BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-2054
Mailing Address - Country:US
Mailing Address - Phone:408-364-6799
Mailing Address - Fax:408-378-4510
Practice Address - Street 1:4400 CAPITOLA RD STE 200
Practice Address - Street 2:
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-3571
Practice Address - Country:US
Practice Address - Phone:931-426-9302
Practice Address - Fax:408-378-4510
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-21
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27266103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY27266OtherBOARD OF PSYCHOLOGY LICENSE