Provider Demographics
NPI:1245356005
Name:JOHNSON, STEPHEN ALLEN
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ALLEN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 E GRANDVIEW ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-4909
Mailing Address - Country:US
Mailing Address - Phone:417-833-4385
Mailing Address - Fax:
Practice Address - Street 1:1550 E BATTLEFIELD ST STE A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-3700
Practice Address - Country:US
Practice Address - Phone:417-869-9011
Practice Address - Fax:417-889-6307
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000276101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional