Healthcare Provider Details

I. General information

NPI: 1962954180
Provider Name (Legal Business Name): ANIKA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 06/11/2023
Certification Date: 06/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 MACKEY PL STE 135
SHREVEPORT LA
71118-2528
US

IV. Provider business mailing address

4650 BETHUME DR
SHREVEPORT LA
71109-6634
US

V. Phone/Fax

Practice location:
  • Phone: 318-220-8423
  • Fax:
Mailing address:
  • Phone: 318-751-7856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number811240931
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: