Provider Demographics
NPI:1619262565
Name:JOHNSON, BREANNA DASJINAY
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:DASJINAY
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 1:1100 N MARTIN LUTHER KING BLVD
Mailing Address - Street 2:STE. C
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-2853
Mailing Address - Country:US
Mailing Address - Phone:702-810-4830
Mailing Address - Fax:
Practice Address - Street 1:1100 N MARTIN LUTHER KING BLVD
Practice Address - Street 2:STE. C
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-2853
Practice Address - Country:US
Practice Address - Phone:702-810-4830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1669776092Medicaid