Healthcare Provider Details

I. General information

NPI: 1871188953
Provider Name (Legal Business Name): CONNIE LEE JOHNSTON RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 GARDEN ST
CRESTVIEW FL
32536-1754
US

IV. Provider business mailing address

416 GARDEN ST
CRESTVIEW FL
32536-1754
US

V. Phone/Fax

Practice location:
  • Phone: 850-329-8641
  • Fax: 850-331-1480
Mailing address:
  • Phone: 850-329-8641
  • Fax: 850-331-1480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: