Healthcare Provider Details

I. General information

NPI: 1194286005
Provider Name (Legal Business Name): KADEEM DAVID JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 07/10/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 MARK DRIVE
WALLINGFORD CT
06492
US

IV. Provider business mailing address

2 PARK PL APT 18E
HARTFORD CT
06106-5016
US

V. Phone/Fax

Practice location:
  • Phone: 203-265-0981
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: