Provider Demographics
NPI:1497295349
Name:JOHNSON, GREGORY
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 W WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-4562
Mailing Address - Country:US
Mailing Address - Phone:352-408-4155
Mailing Address - Fax:
Practice Address - Street 1:831 W WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-4562
Practice Address - Country:US
Practice Address - Phone:352-408-4155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-26
Last Update Date:2017-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician