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NPI Code Detail

MEDICARE: MR. GEORDAN LEGETTE JOHNSON

MEDICARE: MR. GEORDAN LEGETTE JOHNSON
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103T00000XPsychologistS66991897MA

General Provider Information

NPI Number : 1194035774
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. GEORDAN LEGETTE JOHNSON
Provider Business Mailing Address
First Line : 175 WOODROW AVE
Second Line :
City : DORCHESTER CENTER
State : MA
Zip : 02124-3210
Country : US
Telephone Number : 617-388-8139
Fax Number :
Provider Business Practice Location Address
First Line : 504 DUDLEY ST
Second Line :
City : ROXBURY
State : MA
Zip : 02119-2732
Country : US
Telephone Number : 617-445-6655
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/15/2010
Last Update Date : 10/15/2010

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Directions to “ MR. GEORDAN LEGETTE JOHNSON ” Practice Location

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