MEDICARE: MS. KENYATTA 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	106E00000X	Assistant Behavior Analyst

General Provider Information

NPI Number	:	1528740248
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KENYATTA JOHNSON

Provider Business Mailing Address
First Line	:	1516 BEVERLY TER
Second Line	:
City	:	CHERRY HILL
State	:	NJ
Zip	:	08003-3626
Country	:	US
Telephone Number	:	609-271-1642
Fax Number	:

Provider Business Practice Location Address
First Line	:	1516 BEVERLY TER
Second Line	:
City	:	CHERRY HILL
State	:	NJ
Zip	:	08003-3626
Country	:	US
Telephone Number	:	609-271-1642
Fax Number	:

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

Provider Enumeration Date	:	08/02/2023
Last Update Date	:	08/02/2023

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