Provider Demographics
NPI:1376291096
Name:JOHNSON, LESLIE LASHAE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:LASHAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:LESLIE
Other - Middle Name:LASHAE
Other - Last Name:LOFTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3556 N TILLOTSON AVE APT 208
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-1623
Mailing Address - Country:US
Mailing Address - Phone:765-716-6534
Mailing Address - Fax:
Practice Address - Street 1:3715 S MADISON ST
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47302-5756
Practice Address - Country:US
Practice Address - Phone:765-283-4329
Practice Address - Fax:800-546-2329
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-11
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02314770106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst