Provider Demographics
NPI:1225474497
Name:JOHNSON, TARA LYNN
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
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 1:935 CLIPPER DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-5648
Mailing Address - Country:US
Mailing Address - Phone:702-485-8358
Mailing Address - Fax:
Practice Address - Street 1:5659 DUNCAN DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-2811
Practice Address - Country:US
Practice Address - Phone:702-385-2020
Practice Address - Fax:702-658-6608
Is Sole Proprietor?:No
Enumeration Date:2013-05-15
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171M00000XOther Service ProvidersCase Manager/Care Coordinator