Provider Demographics
NPI:1689087298
Name:JOHNSON, DONTE' RASHAD (MAE, BA)
Entity Type:Individual
Prefix:MR
First Name:DONTE'
Middle Name:RASHAD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MAE, BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13571 EAGLE RIDGE DR APT 1325
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-6811
Mailing Address - Country:US
Mailing Address - Phone:419-377-5434
Mailing Address - Fax:
Practice Address - Street 1:1001 E BAKER ST STE 202
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-3700
Practice Address - Country:US
Practice Address - Phone:813-545-0467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45-4924934Medicaid