Provider Demographics
NPI:1700224144
Name:JOHNSON, CANDI RENAE
Entity Type:Individual
Prefix:MISS
First Name:CANDI
Middle Name:RENAE
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 1:87 TWIN OAK PL
Mailing Address - Street 2:
Mailing Address - City:MC KEE
Mailing Address - State:KY
Mailing Address - Zip Code:40447-7190
Mailing Address - Country:US
Mailing Address - Phone:606-493-6176
Mailing Address - Fax:
Practice Address - Street 1:87 TWIN OAK PL
Practice Address - Street 2:
Practice Address - City:MC KEE
Practice Address - State:KY
Practice Address - Zip Code:40447-7190
Practice Address - Country:US
Practice Address - Phone:606-493-6176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY201153621222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist