Healthcare Provider Details

I. General information

NPI: 1275973257
Provider Name (Legal Business Name): COURTNEY BETH JOHNSON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2013
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 E MAIN ST STE 114
PLAINFIELD IN
46168-2827
US

IV. Provider business mailing address

5995 S COUNTY ROAD 700 E
PLAINFIELD IN
46168-9062
US

V. Phone/Fax

Practice location:
  • Phone: 317-426-8055
  • Fax: 317-900-1900
Mailing address:
  • Phone: 317-426-8055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20042744A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number20042744A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: