Provider Demographics
NPI:1912615014
Name:JOHNSON, THAD S
Entity Type:Individual
Prefix:
First Name:THAD
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 MOCKINGBIRD LANE
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303
Mailing Address - Country:US
Mailing Address - Phone:334-797-9349
Mailing Address - Fax:
Practice Address - Street 1:3101 MOCKINGBIRD LANE
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303
Practice Address - Country:US
Practice Address - Phone:334-797-9349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide