Provider Demographics
NPI:1962984286
Name:JOHNSON, DESIREE TAYLOR
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:TAYLOR
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 SPRING AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-4304
Mailing Address - Country:US
Mailing Address - Phone:816-797-1994
Mailing Address - Fax:
Practice Address - Street 1:209 S KINGSHIGHWAY ST
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-1693
Practice Address - Country:US
Practice Address - Phone:816-797-1994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer