Provider Demographics
NPI:1174030894
Name:JOHNSON, IVY (LPC)
Entity Type:Individual
Prefix:DR
First Name:IVY
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 1:4115 MINERAL HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77048-5555
Mailing Address - Country:US
Mailing Address - Phone:713-409-2979
Mailing Address - Fax:
Practice Address - Street 1:4115 MINERAL HAVEN DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77048-5555
Practice Address - Country:US
Practice Address - Phone:713-409-2979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70848103TS0200X
TX67180101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool