Healthcare Provider Details

I. General information

NPI: 1851816524
Provider Name (Legal Business Name): MISTY LOVE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2664 S HARPER RD
CORINTH MS
38834-6723
US

IV. Provider business mailing address

2664 S HARPER RD
CORINTH MS
38834-6723
US

V. Phone/Fax

Practice location:
  • Phone: 662-287-4055
  • Fax: 662-287-4114
Mailing address:
  • Phone: 662-287-4055
  • Fax: 662-287-4114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: