Healthcare Provider Details

I. General information

NPI: 1023824273
Provider Name (Legal Business Name): ELIZABETH GRACE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2024
Last Update Date: 12/03/2024
Certification Date: 11/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 N. CHRISTOBAL ROAD
MARY ESTHER FL
32569
US

IV. Provider business mailing address

140 N. CHRISTOBAL ROAD
MARY ESTHER FL
32569
US

V. Phone/Fax

Practice location:
  • Phone: 844-729-2242
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-390638
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: