Healthcare Provider Details

I. General information

NPI: 1396444683
Provider Name (Legal Business Name): CALLIE JOHNSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N STATE ST
JERSEYVILLE IL
62052-1754
US

IV. Provider business mailing address

240 E MAIN ST
GOOD HOPE IL
61438-9161
US

V. Phone/Fax

Practice location:
  • Phone: 618-498-0190
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178018231
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: