Healthcare Provider Details

I. General information

NPI: 1417423468
Provider Name (Legal Business Name): LARRY JOHNSON B.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2018
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4348 S JEFFREY DR STE 102
BATON ROUGE LA
70816-4196
US

IV. Provider business mailing address

4348 S JEFFREY DR STE 102
BATON ROUGE LA
70816-4196
US

V. Phone/Fax

Practice location:
  • Phone: 225-361-0219
  • Fax:
Mailing address:
  • Phone: 225-361-0219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: