Provider Demographics
NPI:1063953792
Name:JOHNSON, SANQUITA SHANESE
Entity type:Individual
Prefix:
First Name:SANQUITA
Middle Name:SHANESE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 YOUREE DR STE D
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3671
Mailing Address - Country:US
Mailing Address - Phone:318-742-3408
Mailing Address - Fax:
Practice Address - Street 1:555 SAINT TAMMANY ST STE D
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-6064
Practice Address - Country:US
Practice Address - Phone:225-929-9740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-14
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker