Provider Demographics
NPI:1710369616
Name:JOHNSON, LENORA
Entity Type:Individual
Prefix:
First Name:LENORA
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 1:2681 ROOSEVELT BLVD
Mailing Address - Street 2:#9211
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-2512
Mailing Address - Country:US
Mailing Address - Phone:702-985-1441
Mailing Address - Fax:
Practice Address - Street 1:1910 NW 14TH AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-5341
Practice Address - Country:US
Practice Address - Phone:702-985-1441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW127221041C0700X
MI68010950051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical