Healthcare Provider Details

I. General information

NPI: 1174714539
Provider Name (Legal Business Name): BRENDA K JOHNSON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 08/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13305 BROADWAY ST
ALDEN NY
14004-1324
US

IV. Provider business mailing address

845 SUMNER RD
DARIEN CENTER NY
14040-9711
US

V. Phone/Fax

Practice location:
  • Phone: 716-937-4577
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number019746
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: