Provider Demographics
NPI:1861524001
Name:JOHNSON, WILLIAM CARLYLE (PHD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:CARLYLE
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:PO BOX 14169
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27620-4169
Mailing Address - Country:US
Mailing Address - Phone:919-250-3123
Mailing Address - Fax:919-250-3943
Practice Address - Street 1:3010 FALSTAFF RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1813
Practice Address - Country:US
Practice Address - Phone:919-250-3123
Practice Address - Fax:919-250-3943
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1721103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000767Medicaid
NC6000767Medicaid