Provider Demographics
NPI:1336470863
Name:JOHNSON, STACY JEANINE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:JEANINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9109 FOGGY MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-1552
Mailing Address - Country:US
Mailing Address - Phone:704-875-6991
Mailing Address - Fax:
Practice Address - Street 1:9109 FOGGY MEADOWN ROAD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269
Practice Address - Country:US
Practice Address - Phone:704-875-6991
Practice Address - Fax:704-875-6961
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-22
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7711101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional