Provider Demographics
NPI:1760852032
Name:JOHNSON, TACUMA (MDIV)
Entity Type:Individual
Prefix:
First Name:TACUMA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 RIVERDALE DR
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27282-9135
Mailing Address - Country:US
Mailing Address - Phone:336-884-0131
Mailing Address - Fax:336-884-0131
Practice Address - Street 1:5700 RIVERDALE DR
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NC
Practice Address - Zip Code:27282-9135
Practice Address - Country:US
Practice Address - Phone:336-884-0131
Practice Address - Fax:336-884-0131
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist