Healthcare Provider Details

I. General information

NPI: 1497272280
Provider Name (Legal Business Name): TIARA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2017
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2284 S BALLENGER HWY STE G
FLINT MI
48503-3446
US

IV. Provider business mailing address

620 GERMANTOWN PIKE
LAFAYETTE HILL PA
19444-1810
US

V. Phone/Fax

Practice location:
  • Phone: 810-221-7871
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: