Provider Demographics
NPI:1568791929
Name:JOHNSON, LARITA MARLENE (BA)
Entity Type:Individual
Prefix:
First Name:LARITA
Middle Name:MARLENE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-8910
Mailing Address - Country:US
Mailing Address - Phone:580-924-7778
Mailing Address - Fax:
Practice Address - Street 1:119 CHERRY LN
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-8910
Practice Address - Country:US
Practice Address - Phone:580-924-7778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-15
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health