Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | 6678 | MA |
Y | 103TC0700X | Clinical Psychologist | 6678 | MA |
NPI | 1003893900 |
---|---|
Provider Name | Dr. Frederick Vincent Johnson |
First Address | Carver, MA 02330-1128 |
Second Address | Carver, MA 02330-1128 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/12/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
859839 | MA. LIC. HEALTH CARE PROV (01) | MA |