Provider Demographics
NPI:1417602988
Name:JOHNSON, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
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 1:5498 SAINT CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:COTTLEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63304-8020
Mailing Address - Country:US
Mailing Address - Phone:314-495-4198
Mailing Address - Fax:
Practice Address - Street 1:5498 SAINT CHARLES ST
Practice Address - Street 2:
Practice Address - City:COTTLEVILLE
Practice Address - State:MO
Practice Address - Zip Code:63304-8020
Practice Address - Country:US
Practice Address - Phone:314-495-4198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional