Basic Information
| Provider Information | |||||||||
| NPI: | 1265546618 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | MYRIAH | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 PENNSYLVANIA AVENUE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178204906 | ||||||||
| FaxNumber: | 8178204719 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 PENNSYLVANIA AVENUE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178204906 | ||||||||
| FaxNumber: | 8178204719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 02/03/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | M1280 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 188423101 | 05 | TX | MEDICAID |