Healthcare Provider Details

I. General information

NPI: 1386609113
Provider Name (Legal Business Name): MICHAEL EUGENE JOHNSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 05/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 WEST WARNER ROAD SUITE 104
TEMPE AZ
85284
US

IV. Provider business mailing address

430 WEST WARNER ROAD SUITE 104
TEMPE AZ
85284
US

V. Phone/Fax

Practice location:
  • Phone: 602-421-7481
  • Fax: 580-785-0751
Mailing address:
  • Phone: 602-421-7481
  • Fax: 480-785-0751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number3462
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3462
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: