Provider Demographics
NPI:1184913238
Name:JOHNSON, PEARL M (PHD LCSW)
Entity type:Individual
Prefix:DR
First Name:PEARL
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11333 SUGAR PINE DR
Mailing Address - Street 2:STE. 901
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-6734
Mailing Address - Country:US
Mailing Address - Phone:314-803-2808
Mailing Address - Fax:
Practice Address - Street 1:11333 SUGAR PINE DR
Practice Address - Street 2:STE. 901
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-6734
Practice Address - Country:US
Practice Address - Phone:314-803-2808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-29
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0011801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493347207Medicaid