Provider Demographics
NPI:1982325767
Name:JOHNSON, TANESHA (RBT)
Entity Type:Individual
Prefix:MS
First Name:TANESHA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8200 OLD DEXTER RD STE 103
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-0542
Mailing Address - Country:US
Mailing Address - Phone:901-249-2298
Mailing Address - Fax:
Practice Address - Street 1:8200 OLD DEXTER RD STE 103
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-0542
Practice Address - Country:US
Practice Address - Phone:901-249-2298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22207347106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician