Healthcare Provider Details

I. General information

NPI: 1871792192
Provider Name (Legal Business Name): CONNIE JOHNSON, LPC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2007
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 PENDLETON ST
TEMPLE TX
76504-2947
US

IV. Provider business mailing address

PO BOX 581
SALADO TX
76571-0581
US

V. Phone/Fax

Practice location:
  • Phone: 254-742-1524
  • Fax:
Mailing address:
  • Phone: 254-760-2960
  • Fax: 254-947-5069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number14874
License Number StateTX

VIII. Authorized Official

Name: CONNIE JOHNSON
Title or Position: PSYCHOTHERAPIST
Credential: MA, LPC
Phone: 254-742-1524