Healthcare Provider Details

I. General information

NPI: 1497274468
Provider Name (Legal Business Name): MS. SHIRLEY LEE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. SHIRLEY LEE JOHNSON

II. Dates (important events)

Enumeration Date: 09/11/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 SAINT PAUL CHURCH RD
MARION LA
71260-4835
US

IV. Provider business mailing address

480 SAINT PAUL CHURCH RD
MARION LA
71260-4835
US

V. Phone/Fax

Practice location:
  • Phone: 318-548-2377
  • Fax:
Mailing address:
  • Phone: 318-548-2377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number003189742
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: