Provider Demographics
NPI:1649734823
Name:JOHNSON, DEASTRA LYSHELL
Entity Type:Individual
Prefix:
First Name:DEASTRA
Middle Name:LYSHELL
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 1:3510 LINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4512
Mailing Address - Country:US
Mailing Address - Phone:318-636-4194
Mailing Address - Fax:318-636-4196
Practice Address - Street 1:3510 LINWOOD AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4512
Practice Address - Country:US
Practice Address - Phone:318-636-4194
Practice Address - Fax:318-636-4196
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator