Provider Demographics
NPI:1265247605
Name:JOHNSON, LASHASTA NICHOLE
Entity type:Individual
Prefix:
First Name:LASHASTA
Middle Name:NICHOLE
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 1:2873 TITUS AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68112-3231
Mailing Address - Country:US
Mailing Address - Phone:405-924-3572
Mailing Address - Fax:
Practice Address - Street 1:2873 TITUS AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68112
Practice Address - Country:NI
Practice Address - Phone:405-924-3572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-12
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities