Basic Information
| Provider Information | |||||||||
| NPI: | 1073902466 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 409 S 2ND ST | ||||||||
| Address2: | SUITE 2F | ||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171041612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172318360 | ||||||||
| FaxNumber: | 7172318358 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 S FRONT ST | ||||||||
| Address2: | 5TH FLOOR BMA | ||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171041619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172318360 | ||||||||
| FaxNumber: | 7172318358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2015 | ||||||||
| LastUpdateDate: | 01/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PS015349 | PA | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 103002852 | 05 | PA | MEDICAID |