Provider Demographics
NPI:1013419977
Name:JOHNSON, TIA KAYSAUNDRA (BCBA 1-19-38888)
Entity Type:Individual
Prefix:MRS
First Name:TIA
Middle Name:KAYSAUNDRA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BCBA 1-19-38888
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 BRIMFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-3205
Mailing Address - Country:US
Mailing Address - Phone:951-813-7405
Mailing Address - Fax:
Practice Address - Street 1:1753 MERIDEN WTBY TPKE
Practice Address - Street 2:
Practice Address - City:MILLDALE
Practice Address - State:CT
Practice Address - Zip Code:06467-6508
Practice Address - Country:US
Practice Address - Phone:203-558-0367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
CA1-19-38888103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1353OtherDEPARTMENT OF PUBLIC HEALTH