Healthcare Provider Details

I. General information

NPI: 1205266335
Provider Name (Legal Business Name): CONSTANCE NEVLIN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. CONNIE JOHNSON

II. Dates (important events)

Enumeration Date: 11/27/2013
Last Update Date: 11/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 S BROADWAY BLDG 100, SUITE 100
EDMOND OK
73013-4038
US

IV. Provider business mailing address

3301 E FOREST PARK DR
OKLAHOMA CITY OK
73121-2225
US

V. Phone/Fax

Practice location:
  • Phone: 405-216-5750
  • Fax:
Mailing address:
  • Phone: 405-537-9333
  • Fax: 405-521-5580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: