Provider Demographics
NPI:1376836296
Name:JOHNSON, ANGELA HARLEEN (CM)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:HARLEEN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CM
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 292
Mailing Address - Street 2:
Mailing Address - City:TALIHINA
Mailing Address - State:OK
Mailing Address - Zip Code:74571-0292
Mailing Address - Country:US
Mailing Address - Phone:918-470-2042
Mailing Address - Fax:918-567-4011
Practice Address - Street 1:111 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5363
Practice Address - Country:US
Practice Address - Phone:918-302-7391
Practice Address - Fax:918-423-5255
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23436103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst