Provider Demographics
NPI:1558799262
Name:JOHNSON, LETICIA
Entity Type:Individual
Prefix:
First Name:LETICIA
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 1:663 LOUGHTON ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89178-1219
Mailing Address - Country:US
Mailing Address - Phone:702-412-9989
Mailing Address - Fax:
Practice Address - Street 1:911 N BUFFALO DR
Practice Address - Street 2:#213
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0379
Practice Address - Country:US
Practice Address - Phone:702-942-1774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health