Provider Demographics
NPI:1750763462
Name:JOHNSON, LAQUISHA
Entity type:Individual
Prefix:
First Name:LAQUISHA
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 1:501 SW 75TH ST APT J1
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-1704
Mailing Address - Country:US
Mailing Address - Phone:352-256-6789
Mailing Address - Fax:
Practice Address - Street 1:4440 SW ARCHER RD
Practice Address - Street 2:APT. 2627
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-2256
Practice Address - Country:US
Practice Address - Phone:352-256-6789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108740400Medicaid