Provider Demographics
NPI:1609359116
Name:JOHNSON, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 WEST PARK CENTRAL SQ
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65806
Mailing Address - Country:US
Mailing Address - Phone:844-536-8266
Mailing Address - Fax:844-536-8266
Practice Address - Street 1:134 WEST PARK CENTRAL SQ
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806
Practice Address - Country:US
Practice Address - Phone:844-536-8266
Practice Address - Fax:844-536-8266
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130015641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical