Provider Demographics
NPI:1114278454
Name:JOHNSON, ALTHEA
Entity Type:Individual
Prefix:
First Name:ALTHEA
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 1:674 COLFAX PL
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3006
Mailing Address - Country:US
Mailing Address - Phone:516-295-2525
Mailing Address - Fax:
Practice Address - Street 1:674 COLFAX PL
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-3006
Practice Address - Country:US
Practice Address - Phone:516-295-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist