=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124162763
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY MADELINE JOHNSON PH.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2007
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16306 FOREST GATE RD
-----------------------------------------------------
City | DUBUQUE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52001-9701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-556-7071
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16306 FOREST GATE RD
-----------------------------------------------------
City | DUBUQUE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52001-9701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-556-7071
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 00568
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 00568
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------