Provider Demographics
NPI:1134294614
Name:JOHNSON, MARY LEE (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:MARY LEE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:MARY LEE
Other - Middle Name:
Other - Last Name:HEINZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:931 CAROL LANE
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:IL
Mailing Address - Zip Code:60417-1526
Mailing Address - Country:US
Mailing Address - Phone:815-722-4384
Mailing Address - Fax:815-722-4390
Practice Address - Street 1:62 WEST WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60432
Practice Address - Country:US
Practice Address - Phone:815-722-4384
Practice Address - Fax:815-722-4390
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional