Provider Demographics
NPI:1700779394
Name:JOHNSON, EVAN
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8166 MISSISSIPPI RD
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20724-6123
Mailing Address - Country:US
Mailing Address - Phone:443-745-9166
Mailing Address - Fax:
Practice Address - Street 1:14900 SWEITZER LN
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-2915
Practice Address - Country:US
Practice Address - Phone:301-615-1007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician