Healthcare Provider Details

I. General information

NPI: 1811925613
Provider Name (Legal Business Name): BETH A JOHNSON PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 W WISCONSIN AVE
PEWAUKEE WI
53072-3467
US

IV. Provider business mailing address

N75W23310 N RIDGEVIEW CIR
SUSSEX WI
53089-2063
US

V. Phone/Fax

Practice location:
  • Phone: 262-695-8857
  • Fax: 262-695-8879
Mailing address:
  • Phone: 262-820-1628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2297-057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: