Provider Demographics
NPI:1073229134
Name:JOHNSON, TAYLOR DOLORES FLETCHER
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:DOLORES FLETCHER
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 1:1700 W VAN BUREN AVE
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260-3029
Mailing Address - Country:US
Mailing Address - Phone:575-607-7191
Mailing Address - Fax:
Practice Address - Street 1:510 N DAL PASO ST
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-5930
Practice Address - Country:US
Practice Address - Phone:575-433-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM07991041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM578Medicaid