Provider Demographics
NPI:1750977435
Name:JOHNSON, MILES CARLISLE (MS, LPC)
Entity type:Individual
Prefix:MR
First Name:MILES
Middle Name:CARLISLE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 SANDPINE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7629
Mailing Address - Country:US
Mailing Address - Phone:803-463-9818
Mailing Address - Fax:
Practice Address - Street 1:418A BARR RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-2363
Practice Address - Country:US
Practice Address - Phone:864-280-7208
Practice Address - Fax:803-621-9061
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8025101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional