Provider Demographics
NPI:1184939886
Name:JOHNSON, DETRIAL WILLIAMS (PMFT)
Entity type:Individual
Prefix:
First Name:DETRIAL
Middle Name:WILLIAMS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PMFT
Other - Prefix:
Other - First Name:DEATREAL
Other - Middle Name:DENISE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5707 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-4350
Mailing Address - Country:US
Mailing Address - Phone:813-239-8506
Mailing Address - Fax:813-239-8394
Practice Address - Street 1:5707 N 22ND ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-4350
Practice Address - Country:US
Practice Address - Phone:813-239-8506
Practice Address - Fax:813-239-8394
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPMFT 130106H00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor