Provider Demographics
NPI:1861072449
Name:JOHNSON, MATTIE C
Entity type:Individual
Prefix:
First Name:MATTIE
Middle Name:C
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 1:12436 S WALLACE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-7128
Mailing Address - Country:US
Mailing Address - Phone:773-569-5086
Mailing Address - Fax:
Practice Address - Street 1:12436 S WALLACE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-7128
Practice Address - Country:US
Practice Address - Phone:773-569-5086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician