Healthcare Provider Details

I. General information

NPI: 1023338423
Provider Name (Legal Business Name): ERIC W JOHNSON PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 04/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6677 W THUNDERBIRD RD STE D148
GLENDALE AZ
85306
US

IV. Provider business mailing address

6677 W THUNDERBIRD RD STE D148
GLENDALE AZ
85306-3769
US

V. Phone/Fax

Practice location:
  • Phone: 602-612-5004
  • Fax: 602-843-0044
Mailing address:
  • Phone: 602-612-5004
  • Fax: 602-843-0044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS016730
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-004622
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: