Provider Demographics
NPI:1174058283
Name:JOHNSON, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 CHAPEL CT
Mailing Address - Street 2:
Mailing Address - City:WHITESBORO
Mailing Address - State:TX
Mailing Address - Zip Code:76273-5746
Mailing Address - Country:US
Mailing Address - Phone:817-944-0221
Mailing Address - Fax:
Practice Address - Street 1:8370 US HIGHWAY 82 E
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-2404
Practice Address - Country:US
Practice Address - Phone:817-944-0221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67244101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health