Healthcare Provider Details

I. General information

NPI: 1750186961
Provider Name (Legal Business Name): SYDNEY THOMAS JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2025
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

763 JESSE JOHNSON DR
BLAKELY GA
39823-3224
US

IV. Provider business mailing address

1212 ENTERPRISE RD
COLQUITT GA
39837-7225
US

V. Phone/Fax

Practice location:
  • Phone: 229-894-9612
  • Fax:
Mailing address:
  • Phone: 229-254-6948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: