Provider Demographics
NPI:1336893734
Name:MARY MILLER-JOHNSON
Entity Type:Organization
Organization Name:MARY MILLER-JOHNSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER-JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-879-6062
Mailing Address - Street 1:5420 WOOD CROSSING ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-7920
Mailing Address - Country:US
Mailing Address - Phone:407-879-6062
Mailing Address - Fax:
Practice Address - Street 1:5420 WOOD CROSSING ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811-7920
Practice Address - Country:US
Practice Address - Phone:407-879-6062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-05
Last Update Date:2022-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101952900Medicaid