Provider Demographics
NPI:1245121896
Name:JOHNSON, HENRIETTA
Entity type:Individual
Prefix:
First Name:HENRIETTA
Middle Name:
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 1:4729 GRAND CYPRESS CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-5877
Mailing Address - Country:US
Mailing Address - Phone:919-272-2594
Mailing Address - Fax:919-272-2594
Practice Address - Street 1:4729 GRAND CYPRESS CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-5877
Practice Address - Country:US
Practice Address - Phone:919-272-2594
Practice Address - Fax:919-272-2594
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-11
Last Update Date:2025-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities