Provider Demographics
NPI:1639847296
Name:JOHNSON, BROOKCALLEDA DEEPERLINA
Entity Type:Individual
Prefix:
First Name:BROOKCALLEDA
Middle Name:DEEPERLINA
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 1:1451 PORTOFINO PT APT 201
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-5042
Mailing Address - Country:US
Mailing Address - Phone:904-415-8228
Mailing Address - Fax:
Practice Address - Street 1:1775 W STATE ROAD 434
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5067
Practice Address - Country:US
Practice Address - Phone:407-919-6845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician