Provider Demographics
NPI:1568979235
Name:JOHNSON, STAR
Entity Type:Individual
Prefix:
First Name:STAR
Middle Name:
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 1:201 THORNBERRY BRANCH LN
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32124-3652
Mailing Address - Country:US
Mailing Address - Phone:386-872-4892
Mailing Address - Fax:386-256-2159
Practice Address - Street 1:201 THORNBERRY BRANCH LN
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32124-3652
Practice Address - Country:US
Practice Address - Phone:386-872-4892
Practice Address - Fax:386-256-2159
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-04
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No252Y00000XAgenciesEarly Intervention Provider Agency