Healthcare Provider Details

I. General information

NPI: 1457588733
Provider Name (Legal Business Name): LAQUETTA JOHNSON MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2009
Last Update Date: 10/21/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9520 W PALM LN STE 240
PHOENIX AZ
85037-4448
US

IV. Provider business mailing address

9520 W PALM LN STE 240
PHOENIX AZ
85037-4448
US

V. Phone/Fax

Practice location:
  • Phone: 623-289-1654
  • Fax: 623-233-5189
Mailing address:
  • Phone: 623-289-1654
  • Fax: 623-233-5189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15497
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: