Provider Demographics
NPI:1467812560
Name:JOHNSON, SHANTAE
Entity Type:Individual
Prefix:
First Name:SHANTAE
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 1:5928 THREE OAKS CT
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-5897
Mailing Address - Country:US
Mailing Address - Phone:504-657-8018
Mailing Address - Fax:
Practice Address - Street 1:1500 LAFAYETTE ST
Practice Address - Street 2:STE 150
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70053-5799
Practice Address - Country:US
Practice Address - Phone:504-846-6983
Practice Address - Fax:504-838-5714
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-02
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
LA14026104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty