Provider Demographics
NPI:1871067652
Name:JOHNSON, MARVEA (MED, ATR-BC, LPAT)
Entity type:Individual
Prefix:
First Name:MARVEA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MED, ATR-BC, LPAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95-1017 KUAULI ST APT 122
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-4935
Mailing Address - Country:US
Mailing Address - Phone:502-294-1519
Mailing Address - Fax:
Practice Address - Street 1:8401 SHELBYVILLE RD STE 121
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5586
Practice Address - Country:US
Practice Address - Phone:502-936-6546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYRBT-19-76062106S00000X
KY277581221700000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101Y00000XBehavioral Health & Social Service ProvidersCounselor