Provider Demographics
NPI:1407271711
Name:JOHNSON, LAREISHA
Entity Type:Individual
Prefix:
First Name:LAREISHA
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 1:2436 N NOTTINGHAM WAY APT 79
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-1252
Mailing Address - Country:US
Mailing Address - Phone:405-889-8702
Mailing Address - Fax:
Practice Address - Street 1:2436 N NOTTINGHAM WAY APT 79
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-1252
Practice Address - Country:US
Practice Address - Phone:405-889-8702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-24
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health