Provider Demographics
NPI:1619762085
Name:JOHNSON, DAVID C (LTM)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:
Credentials:LTM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 STATE ST APT 206
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-3435
Mailing Address - Country:US
Mailing Address - Phone:862-378-7856
Mailing Address - Fax:
Practice Address - Street 1:375 STATE ST APT 206
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-3435
Practice Address - Country:US
Practice Address - Phone:862-378-7856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00618600225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty