Provider Demographics
NPI:1013799717
Name:JOHNSON, RUTH ANNETTE
Entity type:Individual
Prefix:
First Name:RUTH
Middle Name:ANNETTE
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 1:6920 ASTER DR
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-4708
Mailing Address - Country:US
Mailing Address - Phone:321-365-3154
Mailing Address - Fax:
Practice Address - Street 1:1320 CULVER DR NE STE 3
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-1104
Practice Address - Country:US
Practice Address - Phone:321-914-4055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician