Provider Demographics
NPI:1427709336
Name:JOHNSON, EDLICIA (AMFT)
Entity type:Individual
Prefix:
First Name:EDLICIA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 HOME ST
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60433-9534
Mailing Address - Country:US
Mailing Address - Phone:815-999-2253
Mailing Address - Fax:
Practice Address - Street 1:1502 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-5236
Practice Address - Country:US
Practice Address - Phone:312-339-8604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208.001028106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist