Provider Demographics
NPI:1255493326
Name:JOHNSON-FANT, ROSE MARIE (LPC)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MARIE
Last Name:JOHNSON-FANT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:ROSE
Other - Middle Name:MARIE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19506 KINGSTON GREEN LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77073-2856
Mailing Address - Country:US
Mailing Address - Phone:281-467-2347
Mailing Address - Fax:281-443-3212
Practice Address - Street 1:19506 KINGSTON GREEN LN
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77073-2856
Practice Address - Country:US
Practice Address - Phone:281-467-2347
Practice Address - Fax:281-443-3212
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20197101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1255493326Medicaid
TX179112103Medicaid