1386904688 NPI number — MR. MARK L JOHNSON PHD

Table of content: MR. MARK L JOHNSON PHD (NPI 1386904688)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386904688 NPI number — MR. MARK L JOHNSON PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
MARK
Provider Middle Name:
L
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386904688
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15047 LOS GATOS BLVD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS GATOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95032-2054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-364-6799
Provider Business Mailing Address Fax Number:
408-378-4510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4400 CAPITOLA RD STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAPITOLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95010-3571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-426-9302
Provider Business Practice Location Address Fax Number:
408-378-4510
Provider Enumeration Date:
05/21/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY27266 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PSY27266 . This is a "BOARD OF PSYCHOLOGY LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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