Healthcare Provider Details

I. General information

NPI: 1235796004
Provider Name (Legal Business Name): BRIAN BURKE JOHNSON PLMHP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2019
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13460 WALSH DR
BOYS TOWN NE
68010-7529
US

IV. Provider business mailing address

2313 N WEBB RD
GRAND ISLAND NE
68803-1743
US

V. Phone/Fax

Practice location:
  • Phone: 531-355-3358
  • Fax: 531-355-3375
Mailing address:
  • Phone: 308-381-8851
  • Fax: 308-381-8853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number11864
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY004540
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: