Provider Demographics
NPI:1821417049
Name:JOHNSON, RENESE M (LPC)
Entity type:Individual
Prefix:
First Name:RENESE
Middle Name:M
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 1:382 LEONA LN
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77414-2096
Mailing Address - Country:US
Mailing Address - Phone:512-270-1918
Mailing Address - Fax:512-727-7720
Practice Address - Street 1:110 N INTERSTATE 35 STE 315 PMB 3311
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-5520
Practice Address - Country:US
Practice Address - Phone:512-270-1918
Practice Address - Fax:512-727-7720
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65174101Y00000X, 101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1821417049Medicaid