Provider Demographics
NPI:1003461054
Name:JOHNSON, LEA S
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:S
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 1:1513 LIATRIS LN
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-5082
Mailing Address - Country:US
Mailing Address - Phone:865-405-1748
Mailing Address - Fax:
Practice Address - Street 1:1513 LIATRIS LN
Practice Address - Street 2:
Practice Address - City:NORTH POLE
Practice Address - State:AK
Practice Address - Zip Code:99705-5082
Practice Address - Country:US
Practice Address - Phone:865-405-1748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health