Basic Information
| Provider Information | |||||||||
| NPI: | 1679023683 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9418 E MONTEGO LN | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711183608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186634493 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 856 TEXAS AVE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711013400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184296938 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2016 | ||||||||
| LastUpdateDate: | 09/25/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 13482 | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.