Provider Demographics
NPI:1376917773
Name:JOHNSON, ANGELA (DIRECTOR)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3418 HIGHWAY 6 S
Mailing Address - Street 2:B 217
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77082-4206
Mailing Address - Country:US
Mailing Address - Phone:713-344-0855
Mailing Address - Fax:
Practice Address - Street 1:3418 HIGHWAY 6 S
Practice Address - Street 2:B 217
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77082-4206
Practice Address - Country:US
Practice Address - Phone:713-344-0855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-23
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness