Provider Demographics
NPI:1982254819
Name:JOHNSON, COREY ANTHONY
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:ANTHONY
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 1:31 CHAMBERLAIN AVE
Mailing Address - Street 2:
Mailing Address - City:LITTLE FERRY
Mailing Address - State:NJ
Mailing Address - Zip Code:07643-1851
Mailing Address - Country:US
Mailing Address - Phone:201-559-1460
Mailing Address - Fax:
Practice Address - Street 1:171 LAKE ST STE 1
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:NJ
Practice Address - Zip Code:07446-2036
Practice Address - Country:US
Practice Address - Phone:201-620-9927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician