Provider Demographics
NPI:1740895531
Name:JOHNSON, TINA LASHAY (LMBT #18043)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:LASHAY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMBT #18043
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6922 LOWEN RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-0192
Mailing Address - Country:US
Mailing Address - Phone:980-273-2003
Mailing Address - Fax:
Practice Address - Street 1:5511 MONROE RD STE 206
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-5503
Practice Address - Country:US
Practice Address - Phone:980-273-2003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X, 171M00000X, 172V00000X
NC18043173C00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171W00000XOther Service ProvidersContractor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No173C00000XOther Service ProvidersReflexologist