Provider Demographics
NPI:1619451176
Name:JOHNSON, CHANTIARA LASHAIE
Entity Type:Individual
Prefix:
First Name:CHANTIARA
Middle Name:LASHAIE
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 1:1608 N CENTENNIAL ST
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-7504
Mailing Address - Country:US
Mailing Address - Phone:228-343-9412
Mailing Address - Fax:
Practice Address - Street 1:1608 N CENTENNIAL ST
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-7504
Practice Address - Country:US
Practice Address - Phone:228-343-9412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician