Provider Demographics
NPI:1922305291
Name:JOHNSON, EARLEANE (QMHA)
Entity Type:Individual
Prefix:
First Name:EARLEANE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2275 RENAISSANCE DR STE D
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-6797
Mailing Address - Country:US
Mailing Address - Phone:702-739-7716
Mailing Address - Fax:702-597-2242
Practice Address - Street 1:2275 RENAISSANCE DR STE D
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6797
Practice Address - Country:US
Practice Address - Phone:702-739-7716
Practice Address - Fax:702-597-2242
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-22
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner