Provider Demographics
NPI:1871693739
Name:JOHNSON, DENVER L (PHD)
Entity type:Individual
Prefix:
First Name:DENVER
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 SAINT ANTHONY DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-5859
Mailing Address - Country:US
Mailing Address - Phone:920-391-6940
Mailing Address - Fax:920-391-4811
Practice Address - Street 1:2900 SAINT ANTHONY DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-5859
Practice Address - Country:US
Practice Address - Phone:920-391-6940
Practice Address - Fax:920-391-4811
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1684103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39102700Medicaid
WI510142673019OtherBCBS
WI1100815Medicare ID - Type Unspecified
WI39102700Medicaid