MEDICARE: DR. ERIC MITCHELL JOHNSON PH.D.

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	103TF0200X	Forensic Psychologist	633	OR

General Provider Information

NPI Number	:	1790813079
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIC MITCHELL JOHNSON PH.D.

Provider Business Mailing Address
First Line	:	1942 NW KEARNEY
Second Line	:	SUITE 21
City	:	PORTLAND
State	:	OR
Zip	:	97209
Country	:	US
Telephone Number	:	503-673-0320
Fax Number	:

Provider Business Practice Location Address
First Line	:	1942 NW KEARNEY ST STE 21
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97209-1463
Country	:	US
Telephone Number	:	503-274-4017
Fax Number	:	503-274-2808

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

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	07/08/2007

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