Provider Demographics
NPI:1154973162
Name:JOHNSON, SHAUNDA
Entity type:Individual
Prefix:
First Name:SHAUNDA
Middle Name:
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 1:101 BANDELIER DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-1823
Mailing Address - Country:US
Mailing Address - Phone:337-962-3699
Mailing Address - Fax:
Practice Address - Street 1:150 INDUSTRIAL PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-8309
Practice Address - Country:US
Practice Address - Phone:337-962-3699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1194103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling