Provider Demographics
NPI:1659880771
Name:JOHNSON, ANGELA MAE (LPC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3277 BAYSHORE PKWY
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-4031
Mailing Address - Country:US
Mailing Address - Phone:636-206-0946
Mailing Address - Fax:
Practice Address - Street 1:255 SPENCER RD STE 101
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-2574
Practice Address - Country:US
Practice Address - Phone:636-477-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-20
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014037902101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2014037902OtherLICENSE NUMBER