Provider Demographics
NPI:1659095149
Name:JOHNSON, AEISHA NICOLE
Entity Type:Individual
Prefix:
First Name:AEISHA
Middle Name:NICOLE
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 1:1500 N ELIZABETH AVE
Mailing Address - Street 2:
Mailing Address - City:FERGUSON
Mailing Address - State:MO
Mailing Address - Zip Code:63135-1240
Mailing Address - Country:US
Mailing Address - Phone:314-915-1729
Mailing Address - Fax:
Practice Address - Street 1:1385 HARKEE DR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-3434
Practice Address - Country:US
Practice Address - Phone:314-831-1391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020011986101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health