Provider Demographics
NPI:1558482661
Name:JOHNSON, HENRY BREAVOID (OTR)
Entity Type:Individual
Prefix:MR
First Name:HENRY
Middle Name:BREAVOID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 E ALLENS LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-1104
Mailing Address - Country:US
Mailing Address - Phone:215-753-9033
Mailing Address - Fax:
Practice Address - Street 1:435 E ALLENS LN
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-1104
Practice Address - Country:US
Practice Address - Phone:215-753-9033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOCC003859L171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor