Provider Demographics
NPI:1215282124
Name:JOHNSON, LERA JOYCE (BCBA-D, BAMC)
Entity type:Individual
Prefix:DR
First Name:LERA
Middle Name:JOYCE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BCBA-D, BAMC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 PEIRCE AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-5813
Mailing Address - Country:US
Mailing Address - Phone:804-339-2811
Mailing Address - Fax:
Practice Address - Street 1:2208 PEIRCE AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-5813
Practice Address - Country:US
Practice Address - Phone:804-339-2811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1-06-2813103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst