Provider Demographics
NPI:1770129876
Name:JOHNSON, MIRANDA (RBT)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4117 ALVESTON DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-2737
Mailing Address - Country:US
Mailing Address - Phone:404-977-0678
Mailing Address - Fax:
Practice Address - Street 1:4117 ALVESTON DR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-2737
Practice Address - Country:US
Practice Address - Phone:404-977-0678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-23
Last Update Date:2019-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-18-58567106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician