Healthcare Provider Details

I. General information

NPI: 1922143940
Provider Name (Legal Business Name): AMY FOWLER JOHNSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5970 FAIRVIEW RD STE 412
CHARLOTTE NC
28210-2105
US

IV. Provider business mailing address

5970 FAIRVIEW RD STE 412
CHARLOTTE NC
28210-2105
US

V. Phone/Fax

Practice location:
  • Phone: 704-222-1150
  • Fax: 704-362-1170
Mailing address:
  • Phone: 704-222-1150
  • Fax: 704-362-1170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: