Provider Demographics
NPI:1770935009
Name:JOHNSON, SHIRLEY RENEE (LPCC-S, LICDC-CS)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:RENEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPCC-S, LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 MILL ST
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-2647
Mailing Address - Country:US
Mailing Address - Phone:614-769-8571
Mailing Address - Fax:614-417-1451
Practice Address - Street 1:196 MILL ST
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-2647
Practice Address - Country:US
Practice Address - Phone:614-769-8571
Practice Address - Fax:614-417-1451
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2022-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH041011101YA0400X
OHE.1800985101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0176372Medicaid