Provider Demographics
NPI:1164816096
Name:JOHNSON, LAURA LEE (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 KINGSTON PL
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:TN
Mailing Address - Zip Code:37174-2912
Mailing Address - Country:US
Mailing Address - Phone:585-329-3956
Mailing Address - Fax:
Practice Address - Street 1:2010 KINGSTON PL
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:TN
Practice Address - Zip Code:37174-2912
Practice Address - Country:US
Practice Address - Phone:585-329-3956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-28
Last Update Date:2015-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1-15-18491103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst