Provider Demographics
NPI:1386212942
Name:JOHNSON, FEDORA WYNN (LPC)
Entity Type:Individual
Prefix:
First Name:FEDORA
Middle Name:WYNN
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 1:10868 REEF SANDS DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79924-1123
Mailing Address - Country:US
Mailing Address - Phone:915-929-0242
Mailing Address - Fax:
Practice Address - Street 1:10868 REEF SANDS DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79924-1123
Practice Address - Country:US
Practice Address - Phone:915-929-0242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX78987101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty