Healthcare Provider Details

I. General information

NPI: 1376075754
Provider Name (Legal Business Name): ELAINE IRENE JOHNSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10630 LITTLE PATUXENT PKWY SUITES 209 AND 209A
COLUMBIA MD
21044-3264
US

IV. Provider business mailing address

10630 LITTLE PATUXENT PKWY SUITES 209 AND 209A
COLUMBIA MD
21044-3264
US

V. Phone/Fax

Practice location:
  • Phone: 410-740-8066
  • Fax: 410-740-8068
Mailing address:
  • Phone: 410-740-8066
  • Fax: 410-740-8068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number03639
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: