Provider Demographics
NPI:1174604169
Name:JOHNSON, PHILIP A (PHD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:A
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 1:325 MARKET ST
Mailing Address - Street 2:SUITE 305-B
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37402-1226
Mailing Address - Country:US
Mailing Address - Phone:423-778-9455
Mailing Address - Fax:423-267-2146
Practice Address - Street 1:325 MARKET ST
Practice Address - Street 2:SUITE 305-B
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37402-1226
Practice Address - Country:US
Practice Address - Phone:423-778-9455
Practice Address - Fax:423-267-2146
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP - 547103TC0700X, 103TC2200X, 103TB0200X, 106H00000X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0043707OtherBCBST PROVIDER NO.
TN0043707OtherBCBST PROVIDER NO.