Provider Demographics
NPI:1881460525
Name:KANG, JOHANA
Entity type:Individual
Prefix:MRS
First Name:JOHANA
Middle Name:
Last Name:KANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOHANA
Other - Middle Name:
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1631 NW SAINT LUCIE WEST BLVD STE 207
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1963
Mailing Address - Country:US
Mailing Address - Phone:772-237-1731
Mailing Address - Fax:
Practice Address - Street 1:1631 NW SAINT LUCIE WEST BLVD STE 207
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1963
Practice Address - Country:US
Practice Address - Phone:772-237-1731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician