Basic Information
| Provider Information | |||||||||
| NPI: | 1568675981 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JOEL | ||||||||
| MiddleName: | JAIME | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 MARRIOTT DRIVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3617773991 | ||||||||
| FaxNumber: | 3617770610 | ||||||||
| Practice Location | |||||||||
| Address1: | 1165 E. MAIN | ||||||||
| Address2: | |||||||||
| City: | ALICE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3616649587 | ||||||||
| FaxNumber: | 3617770610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 16111 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 11315003 | 05 | TX | MEDICAID |