Provider Demographics
NPI:1386234938
Name:JOHNSON, STACIA
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2024 BRAYDEN DR SW
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35603-2476
Mailing Address - Country:US
Mailing Address - Phone:256-654-4820
Mailing Address - Fax:
Practice Address - Street 1:1707 US HIGHWAY 72 W
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35611-2948
Practice Address - Country:US
Practice Address - Phone:256-466-2131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health