Healthcare Provider Details

I. General information

NPI: 1801750351
Provider Name (Legal Business Name): WILLIE JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 STATE HIGHWAY J
HAYTI MO
63851-1200
US

IV. Provider business mailing address

500 STATE HIGHWAY J
HAYTI MO
63851-1200
US

V. Phone/Fax

Practice location:
  • Phone: 573-359-2600
  • Fax:
Mailing address:
  • Phone: 573-359-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: