Provider Demographics
NPI:1205725827
Name:JOHNSON, LILLIE R (MS, ED)
Entity type:Individual
Prefix:
First Name:LILLIE
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1057 E HENRIETTA RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-2635
Mailing Address - Country:US
Mailing Address - Phone:585-353-4491
Mailing Address - Fax:
Practice Address - Street 1:1057 E HENRIETTA RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-2635
Practice Address - Country:US
Practice Address - Phone:585-353-4491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-30
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist