Provider Demographics
NPI:1134540263
Name:JOHNSON, MARY (MED BCBA)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MED BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18044 AUTUMN LEAVES DR
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-5206
Mailing Address - Country:US
Mailing Address - Phone:225-270-2974
Mailing Address - Fax:225-621-2534
Practice Address - Street 1:18044 AUTUMN LEAVES DR
Practice Address - Street 2:
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-5206
Practice Address - Country:US
Practice Address - Phone:225-270-2974
Practice Address - Fax:225-621-2534
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst