Provider Demographics
NPI:1780493239
Name:JOHNSON, LATONYA
Entity type:Individual
Prefix:MS
First Name:LATONYA
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 1:4147 KELLYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-7105
Mailing Address - Country:US
Mailing Address - Phone:704-960-5436
Mailing Address - Fax:
Practice Address - Street 1:4147 KELLYBROOK DR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-7105
Practice Address - Country:US
Practice Address - Phone:704-960-5436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician