Healthcare Provider Details

I. General information

NPI: 1316009574
Provider Name (Legal Business Name): DIANE MARIE JOHNSON MS, LPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS DIANE MARIE RUPP

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5414 SAVANNAH RD
SAINT JOSEPH MO
64505-1146
US

IV. Provider business mailing address

5414 SAVANNAH RD
SAINT JOSEPH MO
64505-1146
US

V. Phone/Fax

Practice location:
  • Phone: 816-364-4292
  • Fax: 816-364-2648
Mailing address:
  • Phone: 816-364-4292
  • Fax: 816-364-2648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number001765
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: