Provider Demographics
NPI:1457588733
Name:JOHNSON, LAQUETTA (MSW)
Entity Type:Individual
Prefix:
First Name:LAQUETTA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9520 W PALM LN STE 240
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-4448
Mailing Address - Country:US
Mailing Address - Phone:623-289-1654
Mailing Address - Fax:623-233-5189
Practice Address - Street 1:9520 W PALM LN STE 240
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-4448
Practice Address - Country:US
Practice Address - Phone:623-289-1654
Practice Address - Fax:623-233-5189
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-15
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
AZ154971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner