MEDICARE: MISS THERA ELESISUS JOHNSON CTRS

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	225800000X	Recreation Therapist

General Provider Information

NPI Number	:	1972906055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS THERA ELESISUS JOHNSON CTRS

Provider Business Mailing Address
First Line	:	2031 NW 184TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33056-2753
Country	:	US
Telephone Number	:	305-502-8923
Fax Number	:	305-624-6804

Provider Business Practice Location Address
First Line	:	2031 NW 184TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33056-2753
Country	:	US
Telephone Number	:	305-502-8923
Fax Number	:	305-624-6804

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

Provider Enumeration Date	:	10/02/2014
Last Update Date	:	10/02/2014

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