Healthcare Provider Details

I. General information

NPI: 1902180524
Provider Name (Legal Business Name): ROBERT JOHNSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2011
Last Update Date: 09/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 STARR VALLEY STREET
DEETH NV
89823
US

IV. Provider business mailing address

57 STARR VALLEY STREET
DEETH NV
89823
US

V. Phone/Fax

Practice location:
  • Phone: 775-752-3695
  • Fax:
Mailing address:
  • Phone: 775-752-3695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBAT042222
License Number StateNV

VIII. Authorized Official

Name: ROBERT LAURAN JOHNSON
Title or Position: BEHAVIOR ANALYST
Credential: BCBA
Phone: 775-752-3695