Healthcare Provider Details

I. General information

NPI: 1992287130
Provider Name (Legal Business Name): MICHAEL RAY JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 09/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 NW 31 AVE SUITE #2000
FT LAUD FL
33311
US

IV. Provider business mailing address

900 NW 31 AVE SUITE #2000
FT LAUD FL
33311
US

V. Phone/Fax

Practice location:
  • Phone: 954-357-4896
  • Fax: 954-357-5058
Mailing address:
  • Phone: 954-357-4896
  • Fax: 954-357-5058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2928
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: