Healthcare Provider Details

I. General information

NPI: 1104226513
Provider Name (Legal Business Name): CHRISTOPHER JOHNSON MA, LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2014
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 HARKLE RD SUITE B
SANTA FE NM
87505-4784
US

IV. Provider business mailing address

917 PLACITA CHACO
SANTA FE NM
87505-6253
US

V. Phone/Fax

Practice location:
  • Phone: 505-603-7958
  • Fax:
Mailing address:
  • Phone: 505-603-7958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0155191
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: