Provider Demographics
NPI:1306394010
Name:JOHNSON, STACI (EDS, NCSP)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:EDS, NCSP
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 348
Mailing Address - Street 2:
Mailing Address - City:HOLDEN
Mailing Address - State:WV
Mailing Address - Zip Code:25625-0348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:66 SCHOOL ST
Practice Address - Street 2:MONAVILLE
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-9605
Practice Address - Country:US
Practice Address - Phone:304-792-2089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVU8N131600211103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool