Provider Demographics
NPI:1790233898
Name:JOHNSON, STACEY L (LPCC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12160 SUMMERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD TWP
Mailing Address - State:OH
Mailing Address - Zip Code:44077-8525
Mailing Address - Country:US
Mailing Address - Phone:216-598-5202
Mailing Address - Fax:
Practice Address - Street 1:12160 SUMMERWOOD DR
Practice Address - Street 2:
Practice Address - City:CONCORD TWP
Practice Address - State:OH
Practice Address - Zip Code:44077-8525
Practice Address - Country:US
Practice Address - Phone:216-598-5202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-17
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0003690101YP2500X
OHE.0003690101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0187344Medicaid