Healthcare Provider Details

I. General information

NPI: 1982363453
Provider Name (Legal Business Name): GRYPHON L JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2021
Last Update Date: 02/03/2023
Certification Date: 02/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 MARMION AVE
YOUNGSTOWN OH
44502-2323
US

IV. Provider business mailing address

535 MARMION AVE
YOUNGSTOWN OH
44502-2323
US

V. Phone/Fax

Practice location:
  • Phone: 330-782-5664
  • Fax: 330-782-1614
Mailing address:
  • Phone: 330-782-5664
  • Fax: 330-782-1614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberC.2103639-TRNE
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.2304857
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: