Provider Demographics
NPI:1386485084
Name:JOHNSON, LEAH
Entity type:Individual
Prefix:
First Name:LEAH
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 1:3509 E SHEA BLVD STE 108
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3338
Mailing Address - Country:US
Mailing Address - Phone:480-258-3595
Mailing Address - Fax:
Practice Address - Street 1:3509 E SHEA BLVD STE 108
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3338
Practice Address - Country:US
Practice Address - Phone:480-258-3595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-22870101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor