Basic Information
| Provider Information | |||||||||
| NPI: | 1255513834 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHANSEN | ||||||||
| FirstName: | LEA | ||||||||
| MiddleName: | LAFFOON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D., ABPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2480 LLEWELLYN AVE | ||||||||
| Address2: | |||||||||
| City: | FORT GEORGE G MEADE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207557081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016778895 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2480 LLEWELLYN AVE | ||||||||
| Address2: | |||||||||
| City: | FORT MEADE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016778895 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2007 | ||||||||
| LastUpdateDate: | 11/15/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PY 60192765 | WA | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 37582 | TX | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TP0016X | 305803 | LA | Y | Behavioral Health & Social Service Providers | Psychologist | Prescribing (Medical) |
No ID Information.