Provider Demographics
NPI:1528834249
Name:JOHNSON, SHANIYA OCTAVIA (LMBT)
Entity type:Individual
Prefix:
First Name:SHANIYA
Middle Name:OCTAVIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 GLEN EAGLES DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-5329
Mailing Address - Country:US
Mailing Address - Phone:910-360-3616
Mailing Address - Fax:
Practice Address - Street 1:2912 LYNDHURST AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4006
Practice Address - Country:US
Practice Address - Phone:910-360-3616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20175225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist