Basic Information
| Provider Information | |||||||||
| NPI: | 1467812560 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | SHANTAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5928 THREE OAKS CT | ||||||||
| Address2: | |||||||||
| City: | MARRERO | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700725897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5046578018 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 LAFAYETTE ST | ||||||||
| Address2: | STE 150 | ||||||||
| City: | GRETNA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700535799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048466983 | ||||||||
| FaxNumber: | 5048385714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2016 | ||||||||
| LastUpdateDate: | 08/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 104100000X | 14026 | LA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.