Healthcare Provider Details

I. General information

NPI: 1073902466
Provider Name (Legal Business Name): MARK J JOHNSON PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2015
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 S FRONT ST 5TH FLOOR BMA
HARRISBURG PA
17104-1619
US

IV. Provider business mailing address

409 S 2ND ST SUITE 2F
HARRISBURG PA
17104-1612
US

V. Phone/Fax

Practice location:
  • Phone: 717-231-8360
  • Fax: 717-231-8358
Mailing address:
  • Phone: 717-231-8360
  • Fax: 717-231-8358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS015349
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: