Provider Demographics
NPI:1831257849
Name:JOHNSON, DAVID JAMES (PHD)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:JAMES
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4564 VOYAGEUR DR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505
Mailing Address - Country:US
Mailing Address - Phone:814-866-2729
Mailing Address - Fax:814-790-4122
Practice Address - Street 1:4564 VOYAGEUR DR
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-5422
Practice Address - Country:US
Practice Address - Phone:814-866-2729
Practice Address - Fax:814-790-4122
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-006787-L103TC0700X, 103TC0700X
PAPS006787L104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA215444OtherMEDICARE
11925400OtherCAQH
813628Medicare UPIN