=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821289034
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY SHUMWAY JOHNSON LPCC-S, LICDC-CS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2007
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 WASHINGTON ST
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45662-3914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-505-4500
-----------------------------------------------------
Fax | 740-353-8889
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 WASHINGTON ST
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45662-3914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-505-4500
-----------------------------------------------------
Fax | 740-353-8889
-----------------------------------------------------
=====================================================
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 | 104053
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | E.0600469-SUPV
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------