Provider Demographics
NPI:1629726583
Name:JOHNSON, LEIGHANN (GROUP HOME OWNER)
Entity Type:Individual
Prefix:
First Name:LEIGHANN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:GROUP HOME OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 E HUNT HWY STE 16-226
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-6011
Mailing Address - Country:US
Mailing Address - Phone:928-250-9436
Mailing Address - Fax:
Practice Address - Street 1:1958 E RENEGADE TRL
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-4460
Practice Address - Country:US
Practice Address - Phone:928-250-9436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-10
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
385H00000X
AZ322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No385H00000XRespite Care FacilityRespite Care