Healthcare Provider Details

I. General information

NPI: 1619451176
Provider Name (Legal Business Name): CHANTIARA LASHAIE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1608 N CENTENNIAL ST
HIGH POINT NC
27262-7504
US

IV. Provider business mailing address

1608 N CENTENNIAL ST
HIGH POINT NC
27262-7504
US

V. Phone/Fax

Practice location:
  • Phone: 228-343-9412
  • Fax:
Mailing address:
  • Phone: 228-343-9412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: