Provider Demographics
NPI:1821289034
Name:SHUMWAY JOHNSON, STACEY (LPCC-S, LICDC-CS)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:SHUMWAY JOHNSON
Suffix:
Gender:F
Credentials:LPCC-S, LICDC-CS
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:SHUMWAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPCC-S, LICDC-CS
Mailing Address - Street 1:310 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-3914
Mailing Address - Country:US
Mailing Address - Phone:844-505-4500
Mailing Address - Fax:740-353-8889
Practice Address - Street 1:310 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-3914
Practice Address - Country:US
Practice Address - Phone:844-505-4500
Practice Address - Fax:740-353-8889
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY104053101YP2500X
OHE.0600469-SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
11816332OtherCAQH
000000530777OtherANTHEM BCBS
KY7100283540Medicaid