Healthcare Provider Details

I. General information

NPI: 1265893077
Provider Name (Legal Business Name): FREDA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2016
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13101 BRUCE B DOWNS BLVD
TAMPA FL
33612-3803
US

IV. Provider business mailing address

13101 BRUCE B DOWNS BLVD
TAMPA FL
33612-3803
US

V. Phone/Fax

Practice location:
  • Phone: 813-974-0602
  • Fax: 813-558-1343
Mailing address:
  • Phone: 813-974-0602
  • Fax: 813-558-1343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: