Provider Demographics
NPI:1043839426
Name:JOHNSON, TRACY DARLENE (PLPC)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:DARLENE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 TOWNE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-2339
Mailing Address - Country:US
Mailing Address - Phone:573-474-6600
Mailing Address - Fax:573-474-5995
Practice Address - Street 1:1611 TOWNE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65202-2339
Practice Address - Country:US
Practice Address - Phone:573-474-6600
Practice Address - Fax:573-474-5995
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020010925101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1063586519Medicaid