Provider Demographics
NPI:1780030890
Name:JOHNSON, SHAVESHA LALETTE (MHS)
Entity Type:Individual
Prefix:
First Name:SHAVESHA
Middle Name:LALETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 JOHN WESLEY BLVD
Mailing Address - Street 2:APT 38
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-2299
Mailing Address - Country:US
Mailing Address - Phone:318-560-3093
Mailing Address - Fax:
Practice Address - Street 1:1717 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4139
Practice Address - Country:US
Practice Address - Phone:318-226-9942
Practice Address - Fax:318-226-9944
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health