Provider Demographics
NPI:1013885292
Name:JOHNSON, TYASIA
Entity type:Individual
Prefix:
First Name:TYASIA
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 1:277 E AMADOR AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-3675
Mailing Address - Country:US
Mailing Address - Phone:505-392-3482
Mailing Address - Fax:
Practice Address - Street 1:516 W WALL ST
Practice Address - Street 2:
Practice Address - City:FRACKVILLE
Practice Address - State:PA
Practice Address - Zip Code:17931-2055
Practice Address - Country:US
Practice Address - Phone:267-277-2999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-28
Last Update Date:2025-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician