Provider Demographics
NPI:1598596652
Name:JOHNSON, LOLITA
Entity type:Individual
Prefix:
First Name:LOLITA
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 1:121 WYE OAK DR
Mailing Address - Street 2:
Mailing Address - City:TOWNSEND
Mailing Address - State:DE
Mailing Address - Zip Code:19734-9436
Mailing Address - Country:US
Mailing Address - Phone:302-300-6260
Mailing Address - Fax:
Practice Address - Street 1:4023 KENNETT PIKE # 988
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19807-2018
Practice Address - Country:US
Practice Address - Phone:484-577-9928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DERBT-24-337908103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst