Provider Demographics
NPI:1952803421
Name:JOHNSON, DEANTE M
Entity Type:Individual
Prefix:
First Name:DEANTE
Middle Name:M
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 1:900 PALM AVE APT 9
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-4256
Mailing Address - Country:US
Mailing Address - Phone:650-270-0833
Mailing Address - Fax:
Practice Address - Street 1:3532 ALAMEDA DE LAS PULGAS
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-6510
Practice Address - Country:US
Practice Address - Phone:650-561-9589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49202225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant