Provider Demographics
NPI:1730235219
Name:JOHNSON, HOLLY D (ITDS)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2390 51ST ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-3539
Mailing Address - Country:US
Mailing Address - Phone:727-323-7783
Mailing Address - Fax:727-323-0199
Practice Address - Street 1:2390 51ST ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-3539
Practice Address - Country:US
Practice Address - Phone:727-323-7783
Practice Address - Fax:727-323-0199
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist