Provider Demographics
NPI:1992441133
Name:JOHNSON, LANETA CHANELLE (DT)
Entity type:Individual
Prefix:
First Name:LANETA
Middle Name:CHANELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7445 ROOSEVELT RD APT 206-B
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-2555
Mailing Address - Country:US
Mailing Address - Phone:773-850-5543
Mailing Address - Fax:
Practice Address - Street 1:7445 ROOSEVELT RD APT 206-B
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-2555
Practice Address - Country:US
Practice Address - Phone:773-850-5543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist