Provider Demographics
NPI:1720613250
Name:CARLY JOHNSON
Entity type:Organization
Organization Name:CARLY JOHNSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SELF
Authorized Official - Prefix:
Authorized Official - First Name:CARLY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-940-8918
Mailing Address - Street 1:1500 S DOUGLAS RD STE 230
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-4108
Mailing Address - Country:US
Mailing Address - Phone:844-244-1818
Mailing Address - Fax:
Practice Address - Street 1:4301 FORBES BLVD STE B
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-4446
Practice Address - Country:US
Practice Address - Phone:240-242-5985
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-04
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician