Provider Demographics
NPI:1851841829
Name:JOHNSON, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4019 GREENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71109-6422
Mailing Address - Country:US
Mailing Address - Phone:318-626-5462
Mailing Address - Fax:318-626-5562
Practice Address - Street 1:4019 GREENWOOD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109-6422
Practice Address - Country:US
Practice Address - Phone:318-626-5462
Practice Address - Fax:318-626-5562
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health