Provider Demographics
NPI:1104977800
Name:JOHNSON, CAROL S (LMFT, LPC, CEAP)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMFT, LPC, CEAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 W MAIN ST STE 102
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-3770
Mailing Address - Country:US
Mailing Address - Phone:281-332-3263
Mailing Address - Fax:
Practice Address - Street 1:614 W MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-3770
Practice Address - Country:US
Practice Address - Phone:281-332-3263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8923101YP2500X
TX0179106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
76042119877573OtherTRICARE
TXLP0005876Medicaid
1438LCMedicare ID - Type Unspecified