Provider Demographics
NPI:1053962290
Name:JOHNSON, PARKER SCOTT
Entity type:Individual
Prefix:
First Name:PARKER
Middle Name:SCOTT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5749 WESTGATE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-5040
Mailing Address - Country:US
Mailing Address - Phone:800-969-4310
Mailing Address - Fax:866-265-3695
Practice Address - Street 1:5749 WESTGATE DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-5040
Practice Address - Country:US
Practice Address - Phone:800-969-4310
Practice Address - Fax:866-265-3695
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJ525-677-91-243-0OtherDRIVER'S LICENSE