Provider Demographics
NPI:1821724642
Name:JOHNSON, DAVINE
Entity Type:Individual
Prefix:MISS
First Name:DAVINE
Middle Name:
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 1:24 WEYBOSSET ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02136-6218
Mailing Address - Country:US
Mailing Address - Phone:617-276-2683
Mailing Address - Fax:
Practice Address - Street 1:24 WEYBOSSET ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02136-6218
Practice Address - Country:US
Practice Address - Phone:617-276-2683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician