Provider Demographics
NPI:1568958890
Name:JOHNSON, DETRIC D
Entity Type:Individual
Prefix:
First Name:DETRIC
Middle Name:D
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 1:535 WYOMING AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-3137
Mailing Address - Country:US
Mailing Address - Phone:716-253-1847
Mailing Address - Fax:716-845-3511
Practice Address - Street 1:535 WYOMING AVE STE 1
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-3137
Practice Address - Country:US
Practice Address - Phone:716-253-1847
Practice Address - Fax:716-845-3511
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172V00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes172V00000XOther Service ProvidersCommunity Health Worker