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General NPI Number Information
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NPI Number | 1275806010
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Entity Type | Individual
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Provider Name | LANCE CORDELL JOHNSON
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Gender | Male
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Dates
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Enumeration Date | 02/09/2012
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Last Update Date | 02/09/2012
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Provider Practice Location Address
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Address Line | 7908 NW 23RD ST
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City | BETHANY
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State | OK
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Zip | 73008-4950
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Country | US
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Telephone | 405-636-1463
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Fax |
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Provider Business Mailing Address
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Address Line | 7508 S LINN AVE
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City | OKLAHOMA CITY
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State | OK
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Zip | 73159-4612
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Country | US
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Telephone | 405-443-1481
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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