Provider Demographics
NPI:1871004382
Name:JOHNSON, STACEY LIN (PLMHP)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:LIN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 N BURLINGTON AVE STE C
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-5085
Mailing Address - Country:US
Mailing Address - Phone:402-834-0884
Mailing Address - Fax:888-972-3670
Practice Address - Street 1:303 N BURLINGTON AVE STE C
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-5085
Practice Address - Country:US
Practice Address - Phone:402-834-0884
Practice Address - Fax:888-972-3670
Is Sole Proprietor?:No
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11323101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health