Provider Demographics
NPI:1134742778
Name:JOHNSON, ROSS MATTHEW JR
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:MATTHEW
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1758 WEDGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-7436
Mailing Address - Country:US
Mailing Address - Phone:504-473-1710
Mailing Address - Fax:
Practice Address - Street 1:7240 CROWDER BLVD STE 400
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70127-1923
Practice Address - Country:US
Practice Address - Phone:504-323-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator