Provider Demographics
NPI:1811424286
Name:JOHNSON, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:BRUCE
Other - Middle Name:PROFESSIONAL
Other - Last Name:COUSELING SERVICES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9487 BROOKLINE AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-1429
Mailing Address - Country:US
Mailing Address - Phone:225-930-2993
Mailing Address - Fax:225-930-2991
Practice Address - Street 1:9487 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-1429
Practice Address - Country:US
Practice Address - Phone:225-930-2993
Practice Address - Fax:225-930-2991
Is Sole Proprietor?:No
Enumeration Date:2017-05-17
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health