Healthcare Provider Details

I. General information

NPI: 1104337930
Provider Name (Legal Business Name): TAHEESHA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2017
Last Update Date: 07/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 KINGS CENTER AVE
NORTH LAS VEGAS NV
89032
US

IV. Provider business mailing address

615 KINGS CENTER AVE
NORTH LAS VEGAS NV
89032-1159
US

V. Phone/Fax

Practice location:
  • Phone: 702-716-8005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: