Healthcare Provider Details

I. General information

NPI: 1679023683
Provider Name (Legal Business Name): TIFFANY RANELLE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 01/24/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3341 YOUREE DR STE 10B
SHREVEPORT LA
71105-2149
US

IV. Provider business mailing address

9418 E MONTEGO LN
SHREVEPORT LA
71118-3608
US

V. Phone/Fax

Practice location:
  • Phone: 318-675-0804
  • Fax:
Mailing address:
  • Phone: 318-663-4493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number13482
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: