MEDICARE: DERRICK JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285099473
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DERRICK JOHNSON

Provider Business Mailing Address
First Line	:	5725 PALMA LN
Second Line	:
City	:	GREENWOOD
State	:	FL
Zip	:	32443-2421
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5725 PALMA LN
Second Line	:
City	:	GREENWOOD
State	:	FL
Zip	:	32443-2421
Country	:	US
Telephone Number	:	850-557-7382
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2015
Last Update Date	:	12/15/2015

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Directions to “ DERRICK JOHNSON ” Practice Location

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