Provider Demographics
NPI:1770647083
Name:JOHNSON, LEON (MED, LPC)
Entity Type:Individual
Prefix:MR
First Name:LEON
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4780 FM 603
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:TX
Mailing Address - Zip Code:79510-6148
Mailing Address - Country:US
Mailing Address - Phone:325-668-0665
Mailing Address - Fax:325-673-3310
Practice Address - Street 1:4400 BUFFALO GAP RD
Practice Address - Street 2:STE 3400-C
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-2723
Practice Address - Country:US
Practice Address - Phone:325-668-0665
Practice Address - Fax:325-673-3310
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17598101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX342444OtherMANAGED HEALTH NETWORK
TX6576LCOtherBLUECROSS BLUESHIELD
TX1499873-01Medicaid