Provider Demographics
NPI:1427042076
Name:JOHNSON, CARA RAE (MSW, PSYD)
Entity Type:Individual
Prefix:DR
First Name:CARA
Middle Name:RAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSW, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 KELLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-3811
Mailing Address - Country:US
Mailing Address - Phone:573-582-1234
Mailing Address - Fax:573-581-1981
Practice Address - Street 1:340 KELLEY PKWY
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265
Practice Address - Country:US
Practice Address - Phone:573-582-1234
Practice Address - Fax:573-581-1981
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2023-10-31
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
MO2006016141103TC0700X, 103T00000X
MO0059491041C0700X, 1041C0700X
IL149-0072291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO491638904Medicaid
MO491638904Medicaid
MO223065206Medicare ID - Type UnspecifiedFOR REGION 01 ST. LOUIS
ILK36118Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER