Healthcare Provider Details

I. General information

NPI: 1538376199
Provider Name (Legal Business Name): EMILY THOMAS JOHNSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5779 GETWELL RD STE 3
SOUTHAVEN MS
38672-6347
US

IV. Provider business mailing address

4628 UNION RD
SARDIS MS
38666-3280
US

V. Phone/Fax

Practice location:
  • Phone: 662-510-6507
  • Fax: 844-445-7727
Mailing address:
  • Phone: 662-487-3188
  • Fax: 662-487-3188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number150002
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number46-757
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: