Healthcare Provider Details

I. General information

NPI: 1336912443
Provider Name (Legal Business Name): MIA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2023
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5180 W ATLANTIC AVE
DELRAY BEACH FL
33484-8103
US

IV. Provider business mailing address

6503 N MILITARY TRL APT 400
BOCA RATON FL
33496-2645
US

V. Phone/Fax

Practice location:
  • Phone: 561-674-9996
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-306276
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: