MEDICARE: LANETA CHANELLE JOHNSON DT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1992441133
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LANETA CHANELLE JOHNSON DT

Provider Business Mailing Address
First Line	:	7445 ROOSEVELT RD APT 206-B
Second Line	:
City	:	FOREST PARK
State	:	IL
Zip	:	60130-2555
Country	:	US
Telephone Number	:	773-850-5543
Fax Number	:

Provider Business Practice Location Address
First Line	:	7445 ROOSEVELT RD APT 206-B
Second Line	:
City	:	FOREST PARK
State	:	IL
Zip	:	60130-2555
Country	:	US
Telephone Number	:	773-850-5543
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2022
Last Update Date	:	05/10/2022

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