Provider Demographics
NPI:1215081542
Name:JOHNSON, SALLY A (LPC, CSAC)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 MINERAL POINT AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2970
Mailing Address - Country:US
Mailing Address - Phone:608-756-5555
Mailing Address - Fax:608-756-0174
Practice Address - Street 1:903 MINERAL POINT AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2970
Practice Address - Country:US
Practice Address - Phone:608-756-5555
Practice Address - Fax:608-756-0174
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14553101YP2500X
WI4273101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1215081542OtherBCBSWI
WI39386700Medicaid
WI1215081542Medicaid
WIJOHNSSALOtherMERCYCARE INSURANCE