Provider Demographics
NPI:1932590783
Name:JOHNSON, STACEY (CADC-CAS)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CADC-CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4036 ANDEDON CIR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-5506
Mailing Address - Country:US
Mailing Address - Phone:916-303-0090
Mailing Address - Fax:
Practice Address - Street 1:9121 FOLSOM BLVD STE F
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-2473
Practice Address - Country:US
Practice Address - Phone:916-473-2723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-16
Last Update Date:2025-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
171M00000X, 172V00000X, 372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker