Provider Demographics
NPI:1538376199
Name:JOHNSON, EMILY THOMAS (PHD)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:THOMAS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4628 UNION RD
Mailing Address - Street 2:
Mailing Address - City:SARDIS
Mailing Address - State:MS
Mailing Address - Zip Code:38666-3280
Mailing Address - Country:US
Mailing Address - Phone:662-487-3188
Mailing Address - Fax:662-487-3188
Practice Address - Street 1:5779 GETWELL RD STE 3
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-6347
Practice Address - Country:US
Practice Address - Phone:662-510-6507
Practice Address - Fax:844-445-7727
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS150002103K00000X
MS46-757103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ061267Medicaid
MS02937543Medicaid