Provider Demographics
NPI:1255801650
Name:JOHNSON, LEIDY
Entity type:Individual
Prefix:
First Name:LEIDY
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 1:1796 NEWTON RANSOM BLVD
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-9610
Mailing Address - Country:US
Mailing Address - Phone:570-520-8355
Mailing Address - Fax:
Practice Address - Street 1:1796 NEWTON RANSOM BLVD
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-9610
Practice Address - Country:US
Practice Address - Phone:570-520-8355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst