Provider Demographics
NPI:1326455510
Name:JOHNSON, SHELLY MAE (LPCC)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:MAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 S BEECH ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506-1602
Mailing Address - Country:US
Mailing Address - Phone:419-212-5938
Mailing Address - Fax:419-754-2255
Practice Address - Street 1:113 S BEECH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1602
Practice Address - Country:US
Practice Address - Phone:419-212-5938
Practice Address - Fax:419-784-2255
Is Sole Proprietor?:No
Enumeration Date:2014-07-19
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1300335101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional