Healthcare Provider Details

I. General information

NPI: 1386129864
Provider Name (Legal Business Name): HALLIE M JOHNSON BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2018
Last Update Date: 10/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2404 E EMPIRE ST
BLOOMINGTON IL
61704-3630
US

IV. Provider business mailing address

1200 SEARLE DR APT 1
NORMAL IL
61761-2891
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-8275
  • Fax:
Mailing address:
  • Phone: 130-927-5836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-18-31618
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: