Provider Demographics
NPI:1104178433
Name:JOHNSON, VERONICA (LPC)
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BRIDEKIRK CT
Mailing Address - Street 2:
Mailing Address - City:BLACK JACK
Mailing Address - State:MO
Mailing Address - Zip Code:63033-7422
Mailing Address - Country:US
Mailing Address - Phone:314-607-8961
Mailing Address - Fax:
Practice Address - Street 1:3309 S KINGSHIGHWAY BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-1101
Practice Address - Country:US
Practice Address - Phone:314-620-0043
Practice Address - Fax:314-731-4433
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012029827101YP2500X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical