Provider Demographics
NPI:1033472816
Name:JOHNSON, ANTWONISHA
Entity Type:Individual
Prefix:
First Name:ANTWONISHA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5520 W IDLEWILD AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-8015
Mailing Address - Country:US
Mailing Address - Phone:813-901-3418
Mailing Address - Fax:
Practice Address - Street 1:5520 W IDLEWILD AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-8015
Practice Address - Country:US
Practice Address - Phone:813-901-3418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker