Provider Demographics
NPI:1629569058
Name:JOHNSON, FREDRICK (LPC-MHSP, MED)
Entity type:Individual
Prefix:
First Name:FREDRICK
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LPC-MHSP, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 LAKEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37130-1023
Mailing Address - Country:US
Mailing Address - Phone:615-522-8196
Mailing Address - Fax:615-904-7288
Practice Address - Street 1:1102 DOW ST
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130-2486
Practice Address - Country:US
Practice Address - Phone:615-904-7170
Practice Address - Fax:615-904-7288
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4045101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health