Provider Demographics
NPI:1053856708
Name:JOHNSON, ANITRA
Entity Type:Individual
Prefix:
First Name:ANITRA
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 1:7843 EVERETT AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66112-2130
Mailing Address - Country:US
Mailing Address - Phone:816-447-5248
Mailing Address - Fax:
Practice Address - Street 1:7843 EVERETT AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66112-2130
Practice Address - Country:US
Practice Address - Phone:816-447-5248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSK03321482106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician