Provider Demographics
NPI:1588242416
Name:JOHNSON, CLYDE JOSEPH (PHD)
Entity type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:JOSEPH
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 1:878 FESTIVAL LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-2167
Mailing Address - Country:US
Mailing Address - Phone:865-406-1600
Mailing Address - Fax:
Practice Address - Street 1:1124 BLANTON DR # 100
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-5049
Practice Address - Country:US
Practice Address - Phone:865-286-6950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3637103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service