Provider Demographics
NPI:1104238898
Name:JOHNSON, STELLA M (LCSW)
Entity type:Individual
Prefix:MRS
First Name:STELLA
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2292 CAMELOT CIR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-6000
Mailing Address - Country:US
Mailing Address - Phone:662-231-3064
Mailing Address - Fax:662-844-0683
Practice Address - Street 1:2292 CAMELOT CIR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804
Practice Address - Country:US
Practice Address - Phone:662-231-3064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSCO3691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical