Provider Demographics
NPI:1124229752
Name:JOHNSON, TIFFANY LAINE (LAC, LCDC)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:LAINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LAC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19333 HIGHWAY 59 N
Mailing Address - Street 2:SUITE 280
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77338-4204
Mailing Address - Country:US
Mailing Address - Phone:281-540-0331
Mailing Address - Fax:281-540-0339
Practice Address - Street 1:19333 HIGHWAY 59 N
Practice Address - Street 2:SUITE 280
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-4204
Practice Address - Country:US
Practice Address - Phone:281-540-0331
Practice Address - Fax:281-540-0339
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1227101YA0400X
TX12266101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CV41Medicare ID - Type Unspecified