Provider Demographics
NPI:1467085753
Name:JOHNSON, TINESHA DENISE
Entity Type:Individual
Prefix:
First Name:TINESHA
Middle Name:DENISE
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 1:14840 SHEPARD DR
Mailing Address - Street 2:
Mailing Address - City:DOLTON
Mailing Address - State:IL
Mailing Address - Zip Code:60419-2467
Mailing Address - Country:US
Mailing Address - Phone:773-449-0859
Mailing Address - Fax:
Practice Address - Street 1:14840 SHEPARD DR
Practice Address - Street 2:
Practice Address - City:DOLTON
Practice Address - State:IL
Practice Address - Zip Code:60419-2467
Practice Address - Country:US
Practice Address - Phone:773-449-0859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-15
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No172V00000XOther Service ProvidersCommunity Health Worker
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No374U00000XNursing Service Related ProvidersHome Health Aide