Provider Demographics
NPI:1932753191
Name:JOHANSEN, CHERYL LEE ANN (LADAC)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:LEE ANN
Last Name:JOHANSEN
Suffix:
Gender:F
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3212 RONDA DE LECHUSAS NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1505
Mailing Address - Country:US
Mailing Address - Phone:559-270-0750
Mailing Address - Fax:
Practice Address - Street 1:630 HAINES AVE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1226
Practice Address - Country:US
Practice Address - Phone:505-268-5611
Practice Address - Fax:505-268-5736
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)