Provider Demographics
NPI:1417194812
Name:JOHNSON, ELAINE CARTER
Entity Type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:CARTER
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 1:3106 SARASOTA AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-5610
Mailing Address - Country:US
Mailing Address - Phone:850-819-8486
Mailing Address - Fax:850-747-1482
Practice Address - Street 1:3106 SARASOTA AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-5610
Practice Address - Country:US
Practice Address - Phone:850-819-8486
Practice Address - Fax:850-747-1482
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-03-1119103K00000X
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst