MEDICARE: TIFFANIE ELLIS JOHNSON M.ED, BCBA, LBA

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	0133000178	VA

General Provider Information

NPI Number	:	1982096434
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANIE ELLIS JOHNSON M.ED, BCBA, LBA

Provider Business Mailing Address
First Line	:	1905 HUGUENOT RD STE 305
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23235-4312
Country	:	US
Telephone Number	:	804-690-1980
Fax Number	:

Provider Business Practice Location Address
First Line	:	1905 HUGUENOT RD STE 305
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23235-4312
Country	:	US
Telephone Number	:	804-690-1980
Fax Number	:

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

Provider Enumeration Date	:	02/20/2015
Last Update Date	:	02/20/2015

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