Provider Demographics
NPI:1548077167
Name:JOHNSON, BENJAMIN ERIK
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ERIK
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 1:4291 PERSIMMON PATH
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-1933
Mailing Address - Country:US
Mailing Address - Phone:315-569-6735
Mailing Address - Fax:
Practice Address - Street 1:7293 BUCKLEY RD STE 102
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-2666
Practice Address - Country:US
Practice Address - Phone:315-937-5954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022386-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist