Healthcare Provider Details

I. General information

NPI: 1487006524
Provider Name (Legal Business Name): TALISSA JOHNSON LPC, LMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2016
Last Update Date: 06/30/2024
Certification Date: 06/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 BAYOU PINES EAST DR STE C
LAKE CHARLES LA
70601-7196
US

IV. Provider business mailing address

1000 CHINABERRY DR STE 900
BOSSIER CITY LA
71111-2455
US

V. Phone/Fax

Practice location:
  • Phone: 337-433-3292
  • Fax: 337-433-3293
Mailing address:
  • Phone: 318-459-6795
  • Fax: 318-626-5429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPLPC-8989
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8989
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8989
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: