Provider Demographics
NPI:1235684408
Name:JOHNSON, STACY LEE
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 685
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-0685
Mailing Address - Country:US
Mailing Address - Phone:253-538-2323
Mailing Address - Fax:
Practice Address - Street 1:1307 S 11TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-3644
Practice Address - Country:US
Practice Address - Phone:253-682-2180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-17
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60741726101YA0400X
WACO60237827252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No252Y00000XAgenciesEarly Intervention Provider Agency