Provider Demographics
NPI:1043978695
Name:JOHNSON, ORLISA
Entity Type:Individual
Prefix:
First Name:ORLISA
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 1:2924 KNIGHT ST STE 426
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2414
Mailing Address - Country:US
Mailing Address - Phone:318-754-3560
Mailing Address - Fax:318-779-0439
Practice Address - Street 1:2924 KNIGHT ST STE 426
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2414
Practice Address - Country:US
Practice Address - Phone:318-754-3560
Practice Address - Fax:318-779-0439
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-01
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health