Healthcare Provider Details

I. General information

NPI: 1750694253
Provider Name (Legal Business Name): LYNNETTE JOHNSON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2010
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1641 E FLAMINGO RD SUITE 7
LAS VEGAS NV
89119-5257
US

IV. Provider business mailing address

1641 E FLAMINGO RD SUITE 7
LAS VEGAS NV
89119-5257
US

V. Phone/Fax

Practice location:
  • Phone: 702-434-1564
  • Fax: 702-434-6704
Mailing address:
  • Phone: 702-434-1564
  • Fax: 702-434-6704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number01060
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number01060
License Number StateNV

VIII. Authorized Official

Name: LYNNETTE ELAINE JOHNSON
Title or Position: DIRECTOR
Credential: MA, MFT, LADC
Phone: 702-434-1564