Provider Demographics
NPI:1487298444
Name:JOHNSON, LATONYA RUTH
Entity type:Individual
Prefix:
First Name:LATONYA
Middle Name:RUTH
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 1:411 E NEW ST
Mailing Address - Street 2:
Mailing Address - City:TIMMONSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29161-1543
Mailing Address - Country:US
Mailing Address - Phone:843-496-3810
Mailing Address - Fax:
Practice Address - Street 1:817 BROWN ST
Practice Address - Street 2:
Practice Address - City:BISHOPVILLE
Practice Address - State:SC
Practice Address - Zip Code:29010-1178
Practice Address - Country:US
Practice Address - Phone:843-484-9414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-03
Last Update Date:2019-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health