Provider Demographics
NPI:1194076604
Name:JOHNSON, LYDIA (MA,LPC, ATR)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA,LPC, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2979 N 53RD ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20700 WATERTOWN RD
Practice Address - Street 2:SUIT 102
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1800
Practice Address - Country:US
Practice Address - Phone:262-782-1474
Practice Address - Fax:262-782-1441
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4887-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI84043Medicare PIN