Basic Information
| Provider Information | |||||||||
| NPI: | 1982079901 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | QUAYILA | ||||||||
| MiddleName: | MONEA | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5832 HARTFORD AVE | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708122233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259752546 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 411 COLONIAL DR | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708066506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259269706 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2015 | ||||||||
| LastUpdateDate: | 08/04/2016 | ||||||||
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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 | 101YP2500X | 5482 | LA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 600964601 | 05 | LA | MEDICAID |