Provider Demographics
NPI:1346467768
Name:JOHNSON, TAMARA EVETTE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:EVETTE
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 1:11701 BOB WHITE DR
Mailing Address - Street 2:#4
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77035-2242
Mailing Address - Country:US
Mailing Address - Phone:832-860-0642
Mailing Address - Fax:
Practice Address - Street 1:11701 BOB WHITE DR
Practice Address - Street 2:#4
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77035-2242
Practice Address - Country:US
Practice Address - Phone:832-860-0642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20209101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179801903Medicaid