Provider Demographics
NPI:1538610753
Name:JOHNSON, YOLANDA LATRICE
Entity type:Individual
Prefix:
First Name:YOLANDA
Middle Name:LATRICE
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 1:5048 CHURCH LAKE DR APT 1B
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-8546
Mailing Address - Country:US
Mailing Address - Phone:469-547-3881
Mailing Address - Fax:
Practice Address - Street 1:2165 SPICER CV STE 5
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-5623
Practice Address - Country:US
Practice Address - Phone:469-547-3881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)