Provider Demographics
NPI:1578828281
Name:JOHNSON, TRACEY CREW (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:CREW
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 CHILDRENS WAY
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:FL
Mailing Address - Zip Code:32725-8135
Mailing Address - Country:US
Mailing Address - Phone:386-668-4774
Mailing Address - Fax:386-668-0542
Practice Address - Street 1:51 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:FL
Practice Address - Zip Code:32725-8135
Practice Address - Country:US
Practice Address - Phone:386-668-4774
Practice Address - Fax:386-668-0542
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH11370101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health