Provider Demographics
NPI:1285160051
Name:JOHNSON, KUMAR
Entity type:Individual
Prefix:
First Name:KUMAR
Middle Name:
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 1:5881 NW 57TH CT
Mailing Address - Street 2:APT L208
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33319-2371
Mailing Address - Country:US
Mailing Address - Phone:954-590-0647
Mailing Address - Fax:
Practice Address - Street 1:5881 NW 57TH CT
Practice Address - Street 2:APT L208
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33319-2371
Practice Address - Country:US
Practice Address - Phone:954-590-0647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician