Provider Demographics
NPI:1225893464
Name:JOHNSON, STACI (LAC)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:
Other - Last Name:WATKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 E SOUTHERN AVE STE 735
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-5699
Mailing Address - Country:US
Mailing Address - Phone:480-804-0326
Mailing Address - Fax:480-804-0083
Practice Address - Street 1:2314 S VAL VISTA DR STE 101
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-5591
Practice Address - Country:US
Practice Address - Phone:480-804-0326
Practice Address - Fax:480-804-0083
Is Sole Proprietor?:No
Enumeration Date:2024-02-16
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-22673101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health