Provider Demographics
NPI:1407464738
Name:JOHNSON, LAURA ELIZABETH (MS)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:ELIZABETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 PINO ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-3807
Mailing Address - Country:US
Mailing Address - Phone:228-861-0596
Mailing Address - Fax:
Practice Address - Street 1:1600 BROAD AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-3603
Practice Address - Country:US
Practice Address - Phone:228-863-1132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health