MEDICARE: RICHARD EARL JOHNSON PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	25795	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1008109	OTHER	UT	AMERIGROUP
2	0077TH	OTHER	TX	BCBS PROVIDER ID
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	8B8909	OTHER	TX	BCBS
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306877527
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD EARL JOHNSON PHD

Provider Business Mailing Address
First Line	:	3109 6TH AVE STE B
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-3800
Country	:	US
Telephone Number	:	817-846-8466
Fax Number	:	817-288-0958

Provider Business Practice Location Address
First Line	:	3109 6TH AVE
Second Line	:	STE B
City	:	FORT WORTH
State	:	TX
Zip	:	76110-3800
Country	:	US
Telephone Number	:	817-846-8466
Fax Number	:	817-288-0958

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	05/01/2024

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