Provider Demographics
NPI:1730202508
Name:JOHNSON, ROLANDA MONTEZ
Entity type:Individual
Prefix:
First Name:ROLANDA
Middle Name:MONTEZ
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 1:430 E 162ND ST STE 430
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2258
Mailing Address - Country:US
Mailing Address - Phone:888-825-0058
Mailing Address - Fax:
Practice Address - Street 1:430 E 162ND ST STE 430
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-2258
Practice Address - Country:US
Practice Address - Phone:888-825-0058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist