=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578714127
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARTIN KYLE JOHNSON PSY.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2008
-----------------------------------------------------
Last Update Date | 05/18/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3805 N HIGH ST SUITE 200
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43214-3539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-447-3448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2698
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45501-2698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-447-3448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 6458
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------