Healthcare Provider Details

I. General information

NPI: 1104582717
Provider Name (Legal Business Name): ABBYGAIL JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2021
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

252 CALHOUN ST
WEST POINT MS
39773-3151
US

IV. Provider business mailing address

252 CALHOUN ST
WEST POINT MS
39773-3151
US

V. Phone/Fax

Practice location:
  • Phone: 662-391-1964
  • Fax:
Mailing address:
  • Phone: 662-295-9094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: