Provider Demographics
NPI:1710740154
Name:JOHNSON, REBECCA L
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
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 1:179 E UNIVERSITY BLVD APT 179
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-7027
Mailing Address - Country:US
Mailing Address - Phone:305-753-0066
Mailing Address - Fax:
Practice Address - Street 1:1320 CULVER DR NE STE 3
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-1104
Practice Address - Country:US
Practice Address - Phone:321-904-4055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician