Provider Demographics
NPI:1376876425
Name:JOHNSON, VIVIAN YVETTE (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:VIVIAN
Middle Name:YVETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 LIBERTY ROAD
Mailing Address - Street 2:
Mailing Address - City:GLOSTER
Mailing Address - State:MS
Mailing Address - Zip Code:39638
Mailing Address - Country:US
Mailing Address - Phone:904-278-5036
Mailing Address - Fax:
Practice Address - Street 1:150 OLD LIBERTY ROAD
Practice Address - Street 2:
Practice Address - City:GLOSTER
Practice Address - State:MS
Practice Address - Zip Code:39638
Practice Address - Country:US
Practice Address - Phone:904-278-5036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTO214106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist