Provider Demographics
NPI:1164844379
Name:JOHNSON, ELIZABETH ANNE (LPC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
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 1:10594 MAIN ST
Mailing Address - Street 2:P.O. BOX 1021
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-6038
Mailing Address - Country:US
Mailing Address - Phone:715-416-1381
Mailing Address - Fax:715-934-2091
Practice Address - Street 1:10594 MAIN STREET #1021
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843
Practice Address - Country:US
Practice Address - Phone:715-416-1381
Practice Address - Fax:715-934-2091
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-08
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5875125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100035911Medicaid