Provider Demographics
NPI:1790458156
Name:SUPERVILLE, LIEUTENANT JOHNSON (PHD)
Entity Type:Individual
Prefix:
First Name:LIEUTENANT
Middle Name:JOHNSON
Last Name:SUPERVILLE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7928 EMBASSY BLVD
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33023-6412
Mailing Address - Country:US
Mailing Address - Phone:954-224-4142
Mailing Address - Fax:
Practice Address - Street 1:7928 EMBASSY BLVD
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33023-6412
Practice Address - Country:US
Practice Address - Phone:954-224-4142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11012823363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health