Provider Demographics
NPI:1205401510
Name:JOHNSON, LAUREN
Entity Type:Individual
Prefix:
First Name:LAUREN
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 1:308 FOLCROFT ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-2801
Mailing Address - Country:US
Mailing Address - Phone:443-453-2031
Mailing Address - Fax:443-216-7397
Practice Address - Street 1:9096 REXIS AVE
Practice Address - Street 2:
Practice Address - City:PERRY HALL
Practice Address - State:MD
Practice Address - Zip Code:21128-9021
Practice Address - Country:US
Practice Address - Phone:443-453-2031
Practice Address - Fax:443-216-7397
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRBT-16-24766106S00000X
MD1364103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty