Provider Demographics
NPI:1851913826
Name:JOHNSON, DIRENE
Entity type:Individual
Prefix:
First Name:DIRENE
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:PO BOX 134
Mailing Address - Street 2:
Mailing Address - City:SIBLEY
Mailing Address - State:LA
Mailing Address - Zip Code:71073-0134
Mailing Address - Country:US
Mailing Address - Phone:346-857-9164
Mailing Address - Fax:
Practice Address - Street 1:396 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:SIBLEY
Practice Address - State:LA
Practice Address - Zip Code:71073
Practice Address - Country:US
Practice Address - Phone:318-947-9084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA90351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical