Healthcare Provider Details

I. General information

NPI: 1043517634
Provider Name (Legal Business Name): KATHERINE JOHNSON BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2011
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 MAIN ST SUITE 102
WATERTOWN MA
02472-4411
US

IV. Provider business mailing address

17 MELBOURNE AVE
NEWTON MA
02460-1221
US

V. Phone/Fax

Practice location:
  • Phone: 617-923-7575
  • Fax: 617-663-6252
Mailing address:
  • Phone: 617-923-7575
  • Fax: 617-663-6252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: