Provider Demographics
NPI:1447902655
Name:JOHNSON, TERAH NATHANIEL
Entity type:Individual
Prefix:
First Name:TERAH
Middle Name:NATHANIEL
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 1:4000 OLYMPIA CIR APT 101
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-3614
Mailing Address - Country:US
Mailing Address - Phone:434-202-4080
Mailing Address - Fax:
Practice Address - Street 1:4000 OLYMPIA CIR APT 101
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-3614
Practice Address - Country:US
Practice Address - Phone:434-202-4080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty