Provider Demographics
NPI:1093052961
Name:JOHNSON, DEBRA LEE
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:LEE
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 1:9200 WATSON RD
Mailing Address - Street 2:SUITE G101
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-1528
Mailing Address - Country:US
Mailing Address - Phone:314-544-3800
Mailing Address - Fax:314-843-0552
Practice Address - Street 1:311 S MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-2807
Practice Address - Country:US
Practice Address - Phone:636-281-1990
Practice Address - Fax:636-281-1995
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0050571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical