Healthcare Provider Details

I. General information

NPI: 1700853744
Provider Name (Legal Business Name): REGINALD A. JOHNSON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 11/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4485 WESTMINSTER PL
SAINT LOUIS MO
63108-1812
US

IV. Provider business mailing address

1227 GARDEN VILLAGE DR
FLORISSANT MO
63031-1962
US

V. Phone/Fax

Practice location:
  • Phone: 314-361-0477
  • Fax: 314-830-4630
Mailing address:
  • Phone: 314-503-7608
  • Fax: 314-830-4630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2006000741
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2006000741
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number2006000741
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2006000741
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number2006000741
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: