Provider Demographics
NPI:1306857875
Name:JOHNSON, CONSTANCE (LPC, LPC-SUPERVISOR)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC, LPC-SUPERVISOR
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC, NCC, LPC-SUPERV
Mailing Address - Street 1:PO BOX 581
Mailing Address - Street 2:
Mailing Address - City:SALADO
Mailing Address - State:TX
Mailing Address - Zip Code:76571-0581
Mailing Address - Country:US
Mailing Address - Phone:254-760-2960
Mailing Address - Fax:254-947-5069
Practice Address - Street 1:601 PENDLETON ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-2947
Practice Address - Country:US
Practice Address - Phone:254-742-1524
Practice Address - Fax:254-742-0789
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14874101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX26-0191219OtherPGBA / VALUE OPTIONS TRIC
TX4067LCOtherBLUE CROSS BLUE SHIELD
TX028373101Medicaid