=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649048067
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GLENDA JOHNSON LCMHC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2023
-----------------------------------------------------
Last Update Date | 07/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 OFFICE PARK DR
-----------------------------------------------------
City | MOUNTAIN BRK
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35223-2418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 659-212-6916
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 520 PARK VILLAGE LN
-----------------------------------------------------
City | ALABASTER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35007-7763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-633-1921
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC05232
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 11021
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 63535
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------