Provider Demographics
NPI:1720396732
Name:JOHNSON, SERENA DENISE (LPT)
Entity Type:Individual
Prefix:MS
First Name:SERENA
Middle Name:DENISE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 FORD RD
Mailing Address - Street 2:14A
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-2039
Mailing Address - Country:US
Mailing Address - Phone:610-733-7539
Mailing Address - Fax:215-878-8870
Practice Address - Street 1:5151A WALNUT STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139
Practice Address - Country:US
Practice Address - Phone:610-733-7539
Practice Address - Fax:215-878-8870
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT006315L171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor