Healthcare Provider Details

I. General information

NPI: 1023765740
Provider Name (Legal Business Name): CELOSIA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2022
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 S LOCUST ST
GLENWOOD IA
51534-1727
US

IV. Provider business mailing address

15022 WYCLIFFE DR APT 25
OMAHA NE
68154-4314
US

V. Phone/Fax

Practice location:
  • Phone: 712-527-2823
  • Fax:
Mailing address:
  • Phone: 918-839-0798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number12677
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: