Provider Demographics
NPI:1649465915
Name:JOHNSON, THELMA R
Entity type:Individual
Prefix:
First Name:THELMA
Middle Name:R
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 1:3436 BEAMAN OLD CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SNOW HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28580-8308
Mailing Address - Country:US
Mailing Address - Phone:252-747-5533
Mailing Address - Fax:252-747-5129
Practice Address - Street 1:3436 BEAMAN OLD CREEK RD
Practice Address - Street 2:
Practice Address - City:SNOW HILL
Practice Address - State:NC
Practice Address - Zip Code:28580-8308
Practice Address - Country:US
Practice Address - Phone:252-747-5533
Practice Address - Fax:252-747-5129
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No251S00000XAgenciesCommunity/Behavioral Health