Provider Demographics
NPI:1508340191
Name:JOHNSON, ANNESHA
Entity Type:Individual
Prefix:
First Name:ANNESHA
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 1:2014 MIDYETTE RD APT 205
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-6255
Mailing Address - Country:US
Mailing Address - Phone:786-566-1707
Mailing Address - Fax:
Practice Address - Street 1:2940 E PARK AVE
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-3446
Practice Address - Country:US
Practice Address - Phone:850-643-1033
Practice Address - Fax:850-643-5066
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104150200XMedicaid