Healthcare Provider Details

I. General information

NPI: 1093492696
Provider Name (Legal Business Name): SHAWANDA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2023
Last Update Date: 12/24/2024
Certification Date: 12/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2614 W CENTRAL AVE
TOLEDO OH
43606-3547
US

IV. Provider business mailing address

PO BOX 70651
TOLEDO OH
43607-0651
US

V. Phone/Fax

Practice location:
  • Phone: 419-699-6769
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: