MEDICARE: DR. LYNN DOUGLAS 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	103T00000X	Psychologist	108316-2501	UT

General Provider Information

NPI Number	:	1891709432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LYNN DOUGLAS JOHNSON PH.D.

Provider Business Mailing Address
First Line	:	166 E 5900 S
Second Line	:	STE B-108
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-7257
Country	:	US
Telephone Number	:	801-261-1412
Fax Number	:	801-288-2269

Provider Business Practice Location Address
First Line	:	166 E 5900 S
Second Line	:	STE B-108
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-7257
Country	:	US
Telephone Number	:	801-261-1412
Fax Number	:	801-288-2269

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

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	04/05/2016

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