Doctor Name: | CARLYON J JOHNSON |
NPI Number: | 1104233527 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | |
License Number: | |
Business Practice Address: | 4218 North Grand Blvd St. Louis, MO - 63107 |
Business Phone Number: | 3145346624 |
Business Fax Number: | 3145354394 |
Mailing Address: | 4218 North Grand Blvd, ST. LOUIS |
State: | MO |
Postal Code: | 63107 |
Phone Number: | 3145346624 |
Fax Number: | 3145354394 |
NPI Enumeration Date: | 07/17/2014 |
NPI Last Update Date: | 07/17/2014 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |