Provider Demographics
NPI:1649771650
Name:JOHNSON, ANTHONY TYLER
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:TYLER
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1354 8TH ST SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-1812
Mailing Address - Country:US
Mailing Address - Phone:540-204-3601
Mailing Address - Fax:
Practice Address - Street 1:1354 8TH ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-1812
Practice Address - Country:US
Practice Address - Phone:540-204-3601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-24
Last Update Date:2018-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician