Provider Demographics
NPI:1972859478
Name:JOHNSON, SHANNON (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 STURDY RD STE 3
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-7829
Mailing Address - Country:US
Mailing Address - Phone:219-531-0111
Mailing Address - Fax:219-224-4133
Practice Address - Street 1:1551 STURDY RD STE 3
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-7829
Practice Address - Country:US
Practice Address - Phone:219-531-0111
Practice Address - Fax:219-224-4133
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-02
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001765A101Y00000X, 106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor