Provider Demographics
NPI:1841290236
Name:JOHNSON, NORAH ALICE (PSYD)
Entity type:Individual
Prefix:DR
First Name:NORAH
Middle Name:ALICE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 TEBBETTS AVENUE
Mailing Address - Street 2:PO BOX 326
Mailing Address - City:BELLE
Mailing Address - State:MO
Mailing Address - Zip Code:65013
Mailing Address - Country:US
Mailing Address - Phone:573-859-3744
Mailing Address - Fax:
Practice Address - Street 1:706 TEBBETTS AVENUE
Practice Address - Street 2:
Practice Address - City:BELLE
Practice Address - State:MO
Practice Address - Zip Code:65013
Practice Address - Country:US
Practice Address - Phone:573-859-3744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR0500103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493831242Medicaid