Provider Demographics
NPI:1063019156
Name:JOHNSON BEHAVIORAL HEALTH GROUP
Entity Type:Organization
Organization Name:JOHNSON BEHAVIORAL HEALTH GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ABIGAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:318-379-4488
Mailing Address - Street 1:4830 LINE AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-1530
Mailing Address - Country:US
Mailing Address - Phone:318-379-4488
Mailing Address - Fax:
Practice Address - Street 1:4830 LINE AVE STE 302
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-1530
Practice Address - Country:US
Practice Address - Phone:318-379-4488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)