MEDICARE: DR. ROBERT B. JOHNSON ED.D.

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	1072762501	UT

General Provider Information

NPI Number	:	1609946375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT B. JOHNSON ED.D.

Provider Business Mailing Address
First Line	:	3434 BROOK VIEW LN
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-1592
Country	:	US
Telephone Number	:	801-949-9554
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 S WEST TEMPLE # A110
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-1851
Country	:	US
Telephone Number	:	801-949-9554
Fax Number	:

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

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	07/08/2007

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