Provider Demographics
NPI:1619557345
Name:JOHNSON, DESTINEE
Entity Type:Individual
Prefix:
First Name:DESTINEE
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 1:1012 NW GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-6000
Mailing Address - Country:US
Mailing Address - Phone:405-594-8336
Mailing Address - Fax:832-383-5347
Practice Address - Street 1:1012 NW GRAND BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-6000
Practice Address - Country:US
Practice Address - Phone:405-594-8336
Practice Address - Fax:832-383-5347
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRBT-21-163326106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician