Healthcare Provider Details

I. General information

NPI: 1275806010
Provider Name (Legal Business Name): LANCE CORDELL JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2012
Last Update Date: 02/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7908 NW 23RD ST
BETHANY OK
73008-4950
US

IV. Provider business mailing address

7508 S LINN AVE
OKLAHOMA CITY OK
73159-4612
US

V. Phone/Fax

Practice location:
  • Phone: 405-636-1463
  • Fax:
Mailing address:
  • Phone: 405-443-1481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: