Provider Demographics
NPI:1104792118
Name:JOHNSON, RAEMELL CHERROD (LMT)
Entity type:Individual
Prefix:MR
First Name:RAEMELL
Middle Name:CHERROD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 DEERFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-3024
Mailing Address - Country:US
Mailing Address - Phone:716-482-2028
Mailing Address - Fax:
Practice Address - Street 1:989 KENMORE AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-2924
Practice Address - Country:US
Practice Address - Phone:716-335-9711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-15
Last Update Date:2025-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034052225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist