Provider Demographics
NPI:1215542907
Name:JOHNSON, LEROY LOUIS (CSW)
Entity Type:Individual
Prefix:MR
First Name:LEROY
Middle Name:LOUIS
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-0014
Mailing Address - Country:US
Mailing Address - Phone:505-564-4804
Mailing Address - Fax:505-564-4857
Practice Address - Street 1:1615 OJO COURT
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-564-4804
Practice Address - Fax:505-564-4857
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NM104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker