Healthcare Provider Details

I. General information

NPI: 1629726583
Provider Name (Legal Business Name): LEIGHANN JOHNSON GROUP HOME OWNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2022
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1958 E RENEGADE TRL
SAN TAN VALLEY AZ
85143-4460
US

IV. Provider business mailing address

270 E HUNT HWY STE 16-226
SAN TAN VALLEY AZ
85143-6011
US

V. Phone/Fax

Practice location:
  • Phone: 928-250-9436
  • Fax:
Mailing address:
  • Phone: 928-250-9436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: