MEDICARE: CHARLES JOHNSON PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PS003915	PA

General Provider Information

NPI Number	:	1225078066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES JOHNSON PHD

Provider Business Mailing Address
First Line	:	432 N 6TH ST
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19123-4004
Country	:	US
Telephone Number	:	215-925-2400
Fax Number	:

Provider Business Practice Location Address
First Line	:	1401 S 4TH ST
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19147-5907
Country	:	US
Telephone Number	:	215-339-1079
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	07/08/2007

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Directions to “ CHARLES JOHNSON PHD” Practice Location

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