Provider Demographics
NPI:1609972991
Name:JOHNSON, ELLEN I (MD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:I
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 HOLMES ST
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTE
Mailing Address - State:PA
Mailing Address - Zip Code:16823-1401
Mailing Address - Country:US
Mailing Address - Phone:814-355-6782
Mailing Address - Fax:814-355-6985
Practice Address - Street 1:420 HOLMES ST
Practice Address - Street 2:
Practice Address - City:BELLEFONTE
Practice Address - State:PA
Practice Address - Zip Code:16823-1401
Practice Address - Country:US
Practice Address - Phone:814-355-6782
Practice Address - Fax:814-355-6985
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039807E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAA334449AOtherEMPIRE BLUE CROSS BLUE SHIELD
PA80118OtherHIGHMARK BLUE SHIELD
PA100740OtherCOMMUNITY CARE BEHAVIORAL HEALTH
PA0010965340003Medicaid
PA080118KV5Medicare PIN
PA0010965340003Medicaid