Healthcare Provider Details

I. General information

NPI: 1568655637
Provider Name (Legal Business Name): DEIDRA MCGIE JOHNSON LCP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEIDRA LOUISE MCGIE LMLP

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 10/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 S. ROUSE
PITTSBURG KS
66762
US

IV. Provider business mailing address

1102 S. ROUSE
PITTSBURG KS
66762
US

V. Phone/Fax

Practice location:
  • Phone: 620-231-5310
  • Fax: 620-231-9893
Mailing address:
  • Phone: 620-231-5310
  • Fax: 620-231-9893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberLCP - 269
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberLCP - 269
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: