Provider Demographics
NPI:1225325301
Name:JOHNSON, QUINTRELL DESHAUN SR
Entity Type:Individual
Prefix:MR
First Name:QUINTRELL
Middle Name:DESHAUN
Last Name:JOHNSON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3213 NW 43RD ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-6247
Mailing Address - Country:US
Mailing Address - Phone:405-639-7979
Mailing Address - Fax:
Practice Address - Street 1:3621 N KELLEY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73111-4520
Practice Address - Country:US
Practice Address - Phone:405-524-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)