Provider Demographics
NPI:1124734215
Name:JOHNSON, SHAWNA (BI)
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 REDMAN ST
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2673
Mailing Address - Country:US
Mailing Address - Phone:208-312-1332
Mailing Address - Fax:
Practice Address - Street 1:743 REDMAN ST
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2673
Practice Address - Country:US
Practice Address - Phone:208-312-1332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician