Provider Demographics
NPI:1700405644
Name:JOHNSON, LAURA MICHELLE
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:MICHELLE
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 1:1 SAN JEWELL DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-3308
Mailing Address - Country:US
Mailing Address - Phone:573-489-1564
Mailing Address - Fax:
Practice Address - Street 1:1 SAN JEWELL DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-3308
Practice Address - Country:US
Practice Address - Phone:573-489-1564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-10
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician