Provider Demographics
NPI:1013292861
Name:JOHNSON, ALISA ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:ALISA
Middle Name:ELIZABETH
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 1:4157 S HARVARD AVE STE 118
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2627
Mailing Address - Country:US
Mailing Address - Phone:918-991-5388
Mailing Address - Fax:918-271-5065
Practice Address - Street 1:4157 S HARVARD AVE STE 118
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2627
Practice Address - Country:US
Practice Address - Phone:918-991-5388
Practice Address - Fax:918-271-5065
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200431990AMedicaid