Provider Demographics
NPI:1134294408
Name:JOHNSON, MARCY (LCPC)
Entity Type:Individual
Prefix:
First Name:MARCY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:MARCY
Other - Middle Name:
Other - Last Name:CALDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:4505 E 47TH ST S
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67210-1651
Mailing Address - Country:US
Mailing Address - Phone:316-529-9100
Mailing Address - Fax:316-529-9351
Practice Address - Street 1:4505 E 47TH ST S
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67210-1651
Practice Address - Country:US
Practice Address - Phone:316-529-9100
Practice Address - Fax:316-529-9351
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS859101YM0800X
KS749101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100117700AMedicare ID - Type Unspecified