Basic Information
| Provider Information | |||||||||
| NPI: | 1932753191 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHANSEN | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | LEE ANN | ||||||||
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| Credential: | LADAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3212 RONDA DE LECHUSAS NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871201505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592700750 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 630 HAINES AVE NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871021226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052685611 | ||||||||
| FaxNumber: | 5052685736 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2019 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | NM | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.