Provider Demographics
NPI:1528274297
Name:JOHNSON, MARK ANDREW
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1563 GRAY RD
Mailing Address - Street 2:
Mailing Address - City:UNION SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:13160-4101
Mailing Address - Country:US
Mailing Address - Phone:316-364-8118
Mailing Address - Fax:
Practice Address - Street 1:1563 GRAY RD
Practice Address - Street 2:
Practice Address - City:UNION SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:13160-4101
Practice Address - Country:US
Practice Address - Phone:316-364-8118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000473101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health