Provider Demographics
NPI:1689326167
Name:JOHNSON, DEANNA (MED)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 BUNKERHILL PKWY
Mailing Address - Street 2:
Mailing Address - City:WEST BOYLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:01583-2025
Mailing Address - Country:US
Mailing Address - Phone:774-253-9474
Mailing Address - Fax:
Practice Address - Street 1:62 BUNKERHILL PKWY
Practice Address - Street 2:
Practice Address - City:WEST BOYLSTON
Practice Address - State:MA
Practice Address - Zip Code:01583-2025
Practice Address - Country:US
Practice Address - Phone:774-253-9474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst