Provider Demographics
NPI:1447958749
Name:JOHNSON, REBECCA RUTH
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:RUTH
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 1:24 UNION ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-4906
Mailing Address - Country:US
Mailing Address - Phone:845-239-1736
Mailing Address - Fax:
Practice Address - Street 1:24 UNION ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-4906
Practice Address - Country:US
Practice Address - Phone:845-239-1736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0407175T00000X
NYCPS-3427175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist