Provider Demographics
NPI:1427174994
Name:JOHNSON, SHEILA BLOSSOM (LCPC)
Entity type:Individual
Prefix:
First Name:SHEILA
Middle Name:BLOSSOM
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:MRS
Other - First Name:SHEILA
Other - Middle Name:B
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1561 FRANCIS DR
Mailing Address - Street 2:
Mailing Address - City:PINGREE GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60140-5411
Mailing Address - Country:US
Mailing Address - Phone:847-903-1156
Mailing Address - Fax:847-697-4717
Practice Address - Street 1:1497 N LA FOX ST
Practice Address - Street 2:
Practice Address - City:SOUTH ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60177-1227
Practice Address - Country:US
Practice Address - Phone:847-903-1156
Practice Address - Fax:847-697-4717
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-003949101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180-003949OtherSTATE LICENSE NUMBER