Healthcare Provider Details

I. General information

NPI: 1750984233
Provider Name (Legal Business Name): LAUREN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25601 N LAKELAND BLVD APT 106B
EUCLID OH
44132-2498
US

IV. Provider business mailing address

25601 N LAKELAND BLVD APT 106B
EUCLID OH
44132-2498
US

V. Phone/Fax

Practice location:
  • Phone: 216-857-9831
  • Fax:
Mailing address:
  • Phone: 216-857-9831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number1824431
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: