Provider Demographics
NPI:1750655650
Name:JOHNSON, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
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 1:304 JANET LN
Mailing Address - Street 2:
Mailing Address - City:POCOLA
Mailing Address - State:OK
Mailing Address - Zip Code:74902-3361
Mailing Address - Country:US
Mailing Address - Phone:479-221-7261
Mailing Address - Fax:
Practice Address - Street 1:111 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5363
Practice Address - Country:US
Practice Address - Phone:918-423-5204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-24
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKTEACHER101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor