Provider Demographics
NPI:1497274468
Name:JOHNSON, SHIRLEY LEE
Entity Type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SHIRLEY
Other - Middle Name:LEE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:480 SAINT PAUL CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:LA
Mailing Address - Zip Code:71260-4835
Mailing Address - Country:US
Mailing Address - Phone:318-548-2377
Mailing Address - Fax:
Practice Address - Street 1:480 SAINT PAUL CHURCH RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:LA
Practice Address - Zip Code:71260-4835
Practice Address - Country:US
Practice Address - Phone:318-548-2377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA003189742101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA003189742Medicaid