Healthcare Provider Details

I. General information

NPI: 1154973162
Provider Name (Legal Business Name): SHAUNDA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 INDUSTRIAL PKWY
LAFAYETTE LA
70508-8309
US

IV. Provider business mailing address

101 BANDELIER DR
LAFAYETTE LA
70508-1823
US

V. Phone/Fax

Practice location:
  • Phone: 337-962-3699
  • Fax:
Mailing address:
  • Phone: 337-962-3699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1194
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: