Provider Demographics
NPI:1104143783
Name:JOHNSON, STEPHANIE VAUGHN (LCSW)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:VAUGHN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:DENISE
Other - Last Name:VAUGHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:711 CRAIG LOOP
Mailing Address - Street 2:
Mailing Address - City:ROBELINE
Mailing Address - State:LA
Mailing Address - Zip Code:71469-5205
Mailing Address - Country:US
Mailing Address - Phone:318-472-5367
Mailing Address - Fax:
Practice Address - Street 1:2495 SHREVEPORT HWY 71 NORTH
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71306-9004
Practice Address - Country:US
Practice Address - Phone:318-473-0010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-22
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA73911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical