Healthcare Provider Details

I. General information

NPI: 1700031762
Provider Name (Legal Business Name): KEVIN J JOHNSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2008
Last Update Date: 07/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12805 CULLEN BLVD. D
HOUSTON TX
77047
US

IV. Provider business mailing address

12805 CULLEN BLVD. D
HOUSTON TX
77047
US

V. Phone/Fax

Practice location:
  • Phone: 713-738-6955
  • Fax:
Mailing address:
  • Phone: 713-738-6955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License NumberH0554
License Number StateTX

VIII. Authorized Official

Name: MR. KEVIN JEROME JOHNSON
Title or Position: OWNER
Credential:
Phone: 713-738-6955