Provider Demographics
NPI:1679015283
Name:JOHNSON, CALVIN D JR (LCMT)
Entity Type:Individual
Prefix:MR
First Name:CALVIN
Middle Name:D
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:LCMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:738 UNIVERSITY VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-7611
Mailing Address - Country:US
Mailing Address - Phone:803-754-8432
Mailing Address - Fax:803-754-8411
Practice Address - Street 1:738 UNIVERSITY VILLAGE DR
Practice Address - Street 2:
Practice Address - City:BLYTHEWOOD
Practice Address - State:SC
Practice Address - Zip Code:29016-7611
Practice Address - Country:US
Practice Address - Phone:803-754-8432
Practice Address - Fax:803-754-8411
Is Sole Proprietor?:No
Enumeration Date:2016-11-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9912225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist