Healthcare Provider Details

I. General information

NPI: 1134853591
Provider Name (Legal Business Name): LATOYA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4266 W MAIN ST STE 106
GRAY LA
70359-6421
US

IV. Provider business mailing address

4266 W MAIN ST STE 106
GRAY LA
70359-6421
US

V. Phone/Fax

Practice location:
  • Phone: 504-389-0416
  • Fax:
Mailing address:
  • Phone: 504-389-0416
  • Fax: 985-231-1377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number15952
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number15952
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: