Provider Demographics
NPI:1780363192
Name:JOHNSON, BREANNA
Entity type:Individual
Prefix:
First Name:BREANNA
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 1:900 ROYAL HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5457
Mailing Address - Country:US
Mailing Address - Phone:618-744-7266
Mailing Address - Fax:
Practice Address - Street 1:900 ROYAL HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-5457
Practice Address - Country:US
Practice Address - Phone:618-744-7266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health