Provider Demographics
NPI:1023194685
Name:JOHNSON, SHIRLEY B (MED, LBSW, LPC)
Entity Type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MED, LBSW, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3806 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-2638
Mailing Address - Country:US
Mailing Address - Phone:361-485-0899
Mailing Address - Fax:361-485-0817
Practice Address - Street 1:3806 N MAIN ST
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-2638
Practice Address - Country:US
Practice Address - Phone:361-485-0899
Practice Address - Fax:361-485-0817
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18348101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161116201Medicaid
84827LOtherBCBS