Healthcare Provider Details

I. General information

NPI: 1104917244
Provider Name (Legal Business Name): PAUL BURTON JOHNSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5TH AVE
HINES IL
60141-5000
US

IV. Provider business mailing address

2588 YELLOWSTAR ST
WOODRIDGE IL
60517-1710
US

V. Phone/Fax

Practice location:
  • Phone: 708-202-2469
  • Fax: 708-202-7960
Mailing address:
  • Phone: 630-064-6819
  • Fax: 708-202-7960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: