Provider Demographics
NPI:1366016800
Name:JOHNSON, DESHANDRA
Entity Type:Individual
Prefix:
First Name:DESHANDRA
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 1:1547 PARKWAY
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-4081
Mailing Address - Country:US
Mailing Address - Phone:864-229-7120
Mailing Address - Fax:
Practice Address - Street 1:1547 PARKWAY
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-4081
Practice Address - Country:US
Practice Address - Phone:864-229-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC421504Medicaid
SC335OtherMEDICARE