Provider Demographics
NPI:1386914646
Name:JOHNSON, DEBRA LEE (CM)
Entity type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 948
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465-0948
Mailing Address - Country:US
Mailing Address - Phone:918-453-5502
Mailing Address - Fax:918-458-0499
Practice Address - Street 1:17091 SOUTH MUSKOGEE AVENUE
Practice Address - Street 2:CHEROKEE NATION
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74465-0948
Practice Address - Country:US
Practice Address - Phone:918-453-5502
Practice Address - Fax:918-458-0499
Is Sole Proprietor?:No
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9059171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator