Healthcare Provider Details

I. General information

NPI: 1386904688
Provider Name (Legal Business Name): MARK L JOHNSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 CAPITOLA RD STE 200
CAPITOLA CA
95010-3571
US

IV. Provider business mailing address

15047 LOS GATOS BLVD STE 200
LOS GATOS CA
95032-2054
US

V. Phone/Fax

Practice location:
  • Phone: 931-426-9302
  • Fax: 408-378-4510
Mailing address:
  • Phone: 408-364-6799
  • Fax: 408-378-4510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY27266
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: