Provider Demographics
NPI:1871038091
Name:JOHNSON, LANISE
Entity Type:Individual
Prefix:MRS
First Name:LANISE
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 1:399 MERRILL AVE
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-2227
Mailing Address - Country:US
Mailing Address - Phone:708-203-3760
Mailing Address - Fax:
Practice Address - Street 1:399 MERRILL AVE
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-2227
Practice Address - Country:US
Practice Address - Phone:708-203-3760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-24
Last Update Date:2016-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist