Provider Demographics
NPI:1659975258
Name:JOHNSON, CARLENA LATOYA
Entity Type:Individual
Prefix:MRS
First Name:CARLENA
Middle Name:LATOYA
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 1:5660 SOUTHWYCK BLVD S
Mailing Address - Street 2:SUITE 250
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614
Mailing Address - Country:US
Mailing Address - Phone:419-508-5936
Mailing Address - Fax:567-742-7301
Practice Address - Street 1:5660 SOUTHWYCK BLVD S
Practice Address - Street 2:SUITE 250
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614
Practice Address - Country:US
Practice Address - Phone:419-508-5936
Practice Address - Fax:567-742-7301
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH253Z00000X, 251C00000X, 261QA0600X, 343900000X, 347C00000X, 3747P1801X, 376J00000X, 385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4806277OtherDODD
OH0063351Medicaid