MEDICARE: KEVANYA DEBORAH 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	:	1861107930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVANYA DEBORAH JOHNSON

Provider Business Mailing Address
First Line	:	300 INTERNATIONAL PKWY STE 300
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-5000
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	137 JOHNSON FERRY RD
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30068-4945
Country	:	US
Telephone Number	:	470-648-0510
Fax Number	:

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

Provider Enumeration Date	:	01/23/2023
Last Update Date	:	01/23/2023

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