Healthcare Provider Details

I. General information

NPI: 1023594975
Provider Name (Legal Business Name): SHUNTEL RAMONA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2018
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8891 HOLLEY FARM ROAD
BASTROP LA
71220
US

IV. Provider business mailing address

8891 HOLLEY FARM RD
BASTROP LA
71220-7374
US

V. Phone/Fax

Practice location:
  • Phone: 318-737-6175
  • Fax:
Mailing address:
  • Phone: 318-737-6175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: