Provider Demographics
NPI:1992939797
Name:JOHNSON, PHILIP RUSSELL (LMFTA)
Entity type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:RUSSELL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6113 SAND RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-7601
Mailing Address - Country:US
Mailing Address - Phone:301-471-1537
Mailing Address - Fax:
Practice Address - Street 1:1437 MILITARY CUTOFF RD STE 200
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-3638
Practice Address - Country:US
Practice Address - Phone:301-471-1537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12310A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist