Provider Demographics
NPI:1023160512
Name:JOHNSON, MIA MAUREEN (LPC)
Entity type:Individual
Prefix:MS
First Name:MIA
Middle Name:MAUREEN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:MIA
Other - Middle Name:MAUREEN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:111 ELM LEAF LN
Mailing Address - Street 2:
Mailing Address - City:SCHERTZ
Mailing Address - State:TX
Mailing Address - Zip Code:78154-3504
Mailing Address - Country:US
Mailing Address - Phone:210-842-2607
Mailing Address - Fax:210-662-8440
Practice Address - Street 1:111 ELM LEAF LN
Practice Address - Street 2:
Practice Address - City:SCHERTZ
Practice Address - State:TX
Practice Address - Zip Code:78154-3504
Practice Address - Country:US
Practice Address - Phone:210-842-2607
Practice Address - Fax:210-662-8440
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12890101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTP095890203Medicaid