Healthcare Provider Details

I. General information

NPI: 1225510597
Provider Name (Legal Business Name): DANIELLE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DANIELLE LEITMAN

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 11/09/2022
Certification Date: 10/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 ELM ST
MASSAPEQUA NY
11758-5701
US

IV. Provider business mailing address

30 ELM ST
MASSAPEQUA NY
11758-5701
US

V. Phone/Fax

Practice location:
  • Phone: 516-710-4580
  • Fax:
Mailing address:
  • Phone: 516-710-4580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number14000066125
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: