Provider Demographics
NPI:1598236226
Name:JOHNSON, MARY ELIZABETH SEREY (LC-PC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH SEREY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LC-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 S EAST ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-5918
Mailing Address - Country:US
Mailing Address - Phone:240-236-7200
Mailing Address - Fax:
Practice Address - Street 1:81 W FREDERICK ST
Practice Address - Street 2:
Practice Address - City:WALKERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21793-8216
Practice Address - Country:US
Practice Address - Phone:240-236-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2304101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLC2304OtherLICENSED CLINICAL PROFESSIONAL COUNSELOR