Provider Demographics
NPI:1326661786
Name:JOHNSON, CALVIN A JR (HHP, LMMT)
Entity Type:Individual
Prefix:MR
First Name:CALVIN
Middle Name:A
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:HHP, LMMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3983 LAVISTA RD STE 184
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-5150
Mailing Address - Country:US
Mailing Address - Phone:770-871-9640
Mailing Address - Fax:
Practice Address - Street 1:3983 LAVISTA RD STE 184
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5150
Practice Address - Country:US
Practice Address - Phone:770-871-9640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT008592225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist