MEDICARE: ELIJAH 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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1497566459
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIJAH JOHNSON

Provider Business Mailing Address
First Line	:	14055 CEDAR RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44118-3337
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	14055 CEDAR RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44118-3337
Country	:	US
Telephone Number	:	317-721-8884
Fax Number	:

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

Provider Enumeration Date	:	01/17/2025
Last Update Date	:	01/17/2025

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