Provider Demographics
NPI:1326521212
Name:JOHNSON, STACI (LPC TEXAS BOARD)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC TEXAS BOARD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3610 BELLE STRAIT
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-5073
Mailing Address - Country:US
Mailing Address - Phone:210-286-5292
Mailing Address - Fax:
Practice Address - Street 1:1314 E SONTERRA BLVD STE 2208
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4287
Practice Address - Country:US
Practice Address - Phone:210-858-1900
Practice Address - Fax:210-745-4525
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX71699101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty