Provider Demographics
NPI:1720690829
Name:JOHNSON, CARRIE ELIZABETH (BCBA)
Entity type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:ELIZABETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:ELIZABETH
Other - Last Name:KENCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RBT
Mailing Address - Street 1:2405 PALMER CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6351
Mailing Address - Country:US
Mailing Address - Phone:405-561-7928
Mailing Address - Fax:405-310-9944
Practice Address - Street 1:2405 PALMER CIR STE 100
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6351
Practice Address - Country:US
Practice Address - Phone:405-561-7928
Practice Address - Fax:405-310-9944
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1-21-50622103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200956780Medicaid