Provider Demographics
NPI:1619393188
Name:JOHNSON, DEIRDRE (MAT LAT ATC)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MAT LAT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2429 VILLAGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-3656
Mailing Address - Country:US
Mailing Address - Phone:919-320-8245
Mailing Address - Fax:
Practice Address - Street 1:5500 DIXON DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-4202
Practice Address - Country:US
Practice Address - Phone:919-881-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-08
Last Update Date:2014-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19752255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer